CARINGFORTHEAGES.

COM CARING FOR THE AGES 3

nursing home residents, and even our
hospice patients.
Government Roadblocks
I also don’t generally care for being told
what to do by governmental and regula-
tory bodies, just on general principle. I
don’t think bureaucrats should be practic-
ing medicine or dictating how we should
do it, within reason. Now I hear that
CVS and other pharmacies are going
to start placing 7-day quantity restric-
tions on opioid prescriptions. Arbitrary
limits on daily morphine equivalents
don’t make sense for someone who is
highly tolerant to opioids; a patient with
metastatic prostate cancer who is taking
600 mg a day of oral morphine may
be functioning fine, even though that
would be a lethal dose for you or me.
I hope we as prescribers will do what
needs to be done to ensure our patients
get appropriate treatment, even as addi-
tional roadblocks are placed to make the
prescribing of opioids more inconvenient
and time-consuming. I hope we will not
take paths of less resistance that leave our
patients suffering.
Nonpharmacological measures for
pain can be very helpful, and they have
variable but sometimes decent evidence
to back them up. These include cogni-
tive behavioral therapy, acupuncture,
chiropractic or other manipulative
therapies, physical therapy modalities,
and a variety of other complementary
and alternative medicine interventions.
Also, other classes of medications that
are less prone to serious morbidity can
also be helpful. Other articles in this
issue of Caring discuss some of these
options.
Pain is certainly part of life, but we
need to do what we can to alleviate it
in the people who depend on us to care
for them, and we need to individualize
the treatment plan for each patient.
We need to take into account their
goals of care, and the relative burdens
and benefits of the interventions we
offer. Despite the unfortunate increase
in abuse-related deaths, opioids are still
the mainstay of treatment for severe
pain, and when our patients need them
— just as with the few patients who
really need antipsychotics, despite their
risks — we should not back away from
providing them. We can’t promise our
patients a pain level of zero until their
pulse rate is zero, but we can help them
create realistic expectations for their
pain, and help them cope with the pain
that can’t be eliminated.
And a final reminder, probably not
needed for our readers, but important for
nursing home residents: to paraphrase the
words of Dame Cicely Saunders, the origi-
nator of the modern hospice movement,
“The pen that writes the opiate prescrip-
tion must also write the laxative prescrip-
tion.” An opioid-induced fecal impaction
may cause a lot more pain than the pain
the opioid was prescribed to treat! ¹
Dr. Steinberg, editor in chief of Caring
for the Ages, is a multi-facility and hos-
pice medical director, as well as chair of
the Society’s Public Policy Committee.
The views he expresses are his own and
not necessarily those of the Society or
any other entity. He may be reached at
karlsteinberg@MAIL.com, and he can
be followed on Twitter @karlsteinberg.

New Guidelines Support Deprescribing of Proton Pump Inhibitors

Christine Kilgore

D eprescribing proton pump inhibi-

tors (PPIs) in asymptomatic pa-
tients who do not truly need treatment
can be accomplished through reductions
in both dosage and dosing frequency,
David S. H. Lee, PharmD, PhD, said
at the annual meeting of the American
Geriatrics Society in May 2017.
“Treatment does not have to be
given daily,” said Dr. Lee, of Oregon
State University’s College of Pharmacy.
“Usually, I try to reduce the schedule
down to three times a week, followed
by twice weekly, and then we try once
weekly.”
In addition to sharing his own
experience, Dr. Lee referred to a new
evidence-based clinical practice guide-
line and algorithm from Canada
that also includes “on-demand” and
“intermittent” dosing as PPI depre-
scribing options (Can Fam Physician
2017;63:354–364).
On-demand (or “as-needed”) PPI use
is defined in the guideline as daily intake
for a period sufficient to achieve resolu-
tion of reflux-related symptoms, follow-
ing by discontinuation until symptoms
recur. Intermittent PPI use is defined
as “daily intake of a medication for a
predetermined finite period (usually
2 to 8 weeks) to produce resolution
of reflux-related symptoms or healing of
esophageal lesions following relapse of
the individual’s condition.”
The guideline’s target population is
adults taking continuous PPIs for more
than 28 days for the treatment of mild
to moderate gastroesophageal reflux dis-
ease (GERD) or esophagitis; it does not
include patients with Barrett esophagus,
severe esophagitis or a documented his-
tory of bleeding gastrointestinal ulcers, or
chronic users of nonsteroidal anti-inflam-
matory drugs who have bleeding risk.
Long-term use of PPIs has been
associated with an increased risk for
Clostridium difficile infection, pneumo-
nia, and fractures. In addition to these
“well established risks,” there is “mount-
ing evidence” that PPI use may increase
the risk of renal failure, Dr. Lee said at
the meeting.
Acute kidney injury (AKI) in PPI users
has been regarded as a possible warning
sign for susceptibility to kidney failure
and other long-term renal outcomes.
However, in a recent study of more than
125,000 new PPI users, approximately
45% of those who developed renal fail-
ure did so “without any signs of AKI,”
Dr. Lee noted.
The study of new PPI users was based
on Department of Veteran Affairs data-
bases, from which a national cohort of
new PPI users without kidney disease
was compiled. The findings over 5 years
of follow-up observation “strongly sug-
gest a relationship between PPI use and
the risk of chronic kidney disease and
progression to ESRD [end-stage renal
disease] in the absence of intervening
AKI,” the investigators wrote (Kidney Int
2017;91:1482–1494).
Additionally, Dr. Lee said, there is
some concern about the risk of stroke
with high doses of PPIs. Laboratory
research reported at the 2016 American
Heart Association meeting (and as
yet unpublished) has suggested that
reduced nitric oxide production might
be involved, he said.
Nearly all the studies thus far on
PPIs have been observational studies,
Dr. Lee said, “so we can’t establish causal
links.” But as the research has suggested,
“PPIs are not totally benign. We need to
reserve their use for those who truly need
treatment.”
Development of the new Canadian
guideline has included a systematic review
of PPI deprescribing trials and involved
the Grading of Recommendations,
Assessment, Development and
Evaluations (GRADE) Working Group
approach to making recommendations.
Thus far, according to Barbara Farrell,
use is, on the other hand, a “strong”
recommendation.
No trials have compared a depre-
PharmD, and her guideline coauthors, scribing approach with continuous
there is no evidence that deprescribing PPI use in conditions for which PPI
causes important clinical harms. There treatment is usually of limited duration
also is no evidence that one tapering (such as intensive care unit stress ulcer
approach is better than another. prophylaxis).
There is “very low-quality evidence At the AGS meeting, Dr. Lee noted
that abrupt discontinuation (without that frail older adults are more likely to
tapering or using on-demand strategies) experience adverse effects from depre-
does increase symptom relapse,” the scribing. Future research on PPI depre-
guideline says. “Therefore, it might be scribing should address the frail elderly
prudent to reduce the PPI to the low- population, optimal tapering regimens,
est effective dose before discontinuation and alternate treatments to minimize
and to provide patients with a symptom symptom recurrence, according to
management strategy that might include Dr. Farrell and colleagues.
on-demand PPIs.” The guideline on deprescrib-
Tapering of the PPI dosage followed ing PPIs was developed as part of
by prescription of a histamine-2 (H2) the “Deprescribing Guidelines in the
receptor antagonist is an option, but the Elderly” project (www.deprescribing.
guidelines rate this step-down option as a org). ¹
“weak” recommendation due to a “higher
risk of symptom return.” Lowering the
PPI dosage or stopping regular PPI Christine Kilgore is a freelance writer in
usage and switching to on-demand PPI Falls Church, VA.
EDITOR’S NOTE
There’s no doubt that PPIs are overutilized in nursing homes. Often, patients
with no history of peptic ulcer disease or GERD are started on a PPI in the
hospital for prophylaxis, and it gets continued when they come out to us. It’s
our duty as post-acute and long-term care clinicians to determine whether these
drugs are appropriate or not. PPIs are definitely one of the agents for which we
should consider deprescribing initiatives, and our consultant pharmacists can help
remind us. My usual strategy — even if these guidelines suggest the evidence for
use of H2 blockers as a stepdown is “weak”— is to alternate an H2 blocker with
a PPI every other day, so that each day the patient is at least getting something
in the nature of an acid-reducing medication. Then I can taper down further as
symptoms permit. Remember that some patients do require long-term treatment
with PPIs, and it’s worthwhile to document discussion of risks, benefits and alter-
natives in these cases. Also remember to monitor magnesium, as hypomagnesemia
is another known adverse effect of PPIs.
—Karl Steinberg, MD, CMD, HMDC
Editor in Chief