This is the first Prescribing Portrait produced by the Therapeutics Initiative, in 2020. To view this Portrait in PDF format click on the DOWNLOAD button. If you are a BC family physician and wish to sign up for (or opt out of) receiving Portrait click on the REGISTER button.
Best Evidence for Prescribing PPIs for GERD/Heartburn
Do they work? Yes, PPIs can be effective for heartburn symptoms.
- Specifically: PPIs can improve non-erosive heartburn more than H2RAs (e.g. cimetidine) RR 0.78 and more than placebo RR 0.71.1
How long should a prescription be? Just 4-8 weeks. Most clinical trials for relief of heartburn symptoms with PPIs were this long.1
Harms of Long-Term PPI Prescribing
PPIs are associated with serious harm that increases with duration of exposure, age, and comorbidity. These harms include increased risk for: chronic kidney disease,2 gastric cancer,3 cardiovascular disease, C.difficile and fractures.6 Increase in mortality is controversial and studies are ongoing.6
When PPIs are indicated, they should be prescribed at the lowest dose and shortest time period.
When Long-Term PPIs May Be Appropriate
Long-term use of PPIs may be indicated for some serious conditions such as: moderate‐to‐severe esophagitis, Barrett’s esophagus, Zollinger‐Ellison syndrome, H.pylori, chronic NSAID or anticoagulant use, or peptic ulcer disease.4
Possible Actions for New Prescriptions <12 Weeks:
For new presentations of GERD/heartburn, you could:
- Consider use of prescription H2RA’s, such as cimetidine, or over-the-counter antacids. Include patient instructions to review dietary triggers.8
- Write a 4-week PPI prescription only.
* Document indication and expected length of treatment for new prescriptions. Add this info to each prescription, so your community pharmacy colleague is aware.
Possible Actions for Renewed Prescriptions >12 Weeks:
Instead of renewing, you could:
- Deprescribe the PPI by tapering and/or discontinuing the PPI. Deprescribing has been found to be safe. A Canadian PPI deprescribing guideline was published in 2017.5
* Set a reminder to review patient experience and symptoms of deprescribing decisions in 4 to 12 weeks.
- Change medication use instruction to PRN only.
Data and Definitions Used for This Portrait
- Study period: We counted prescriptions for the 12-month period of December 2018 to November 2019.
- BC doctors: All family doctors registered with CPSBC with BC mailing address who have prescribed ≥25 times in 2018.
- Patients: Community dwelling adults to whom you prescribed a PPI ≥once during the study period.
- Patients excluded: Anyone on Plan P (palliative) or Plan B (long-term care).
- Prescribed: A prescription written using your prescribing number, recorded on PharmaNet.
- PPIs: Pantoprazole, Rabeprazole, Esomeprazole, Lansoprazole, Omeprazole, Dexlansoprazole.
- Length of PPI prescriptions: The cumulative weeks of prescribing of a PPI, by your prescribing number, for each patient. e.g. if a 12w prescription is dispensed 3 times (=36w), that patient counts in the 12-50w category.
References, Additional Reading and Patient Resources
- Sigterman KE, van Pinxteren B, Bonis PA, Lau J, Numans ME. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev. 2013 May 31; (5):CD002095. https://doi.org/10.1002/14651858.CD002095.pub5
- Hussain S, Singh A, Habib A, NajmiAK. Proton pump inhibitors use and risk of chronic kidney disease: Evidence-based meta-analysis of observational studies. Clinical Epidemiology and Global Health. 2019 March; 7(1):46-52. https://doi.org/10.1016/j.cegh.2017.12.008
- Wan QY, Wu XT, Li N, Du L, Zhou Y. Long-term proton pump inhibitors use and risk of gastric cancer: a meta-analysis of 926,386 participants. Gut. 2019 April; 68(4):762-764. https://doi.org/10.1136/gutjnl-2018-316416
- BoghossianTA, Rashid FJ, Thompson W, Welch V, MoayyediP, Rojas‐Fernandez C, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017 March 16; (3):CD011969. https://doi.org/10.1002/14651858.CD011969.pub2
- **PPI Deprescribing Guideline** Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors. Can Fam Physician. 2017 May; 63(5):354–64. http://www.cfp.ca/content/63/5/354 and 2 page summary flowsheet: https://deprescribing.org/wp-content/uploads/2018/08/ppi-deprescribing-algorithm_2018_En.pdf
- Therapeutics Initiative. Serious harms with long-term proton pump inhibitor use in older adults. Therapeutics Letter 126. 2020 (Mar-Apr); 126:1-2. https://ti.ubc.ca/letter126
- Therapeutics Initiative.Trends in utilization of proton pump inhibitors in British Columbia. Therapeutics Letter 118. 2002 (Jun-Sep); 118:1-2. https://ti.ubc.ca/letter118
- 2-page patient info sheet: “Is a Proton Pump Inhibitor still needed?”including lifestyle/diet changes and over the counter remedies: https://deprescribing.org/wp-content/uploads/2018/08/Deprescribing-Pamphlet_PPI_ENG_CFP.pdf by Deprescribing.org
- 12-page, easy-to-read patient workbook: “Do I still Need this Medication? Proton Pump Inhibitor (PPI)” http://www.criugm.qc.ca/fichier/pdf/PPI-EN-Men.pdf at https://www.deprescribingnetwork.ca/deprescribing by Canadian Deprescribing Network (available in multiple languages).