title: Deprescribing versus continuation of chronic proton pump inhibitor use in adults.
abstract: BACKGROUND
  Proton pump inhibitors (PPIs) are a class of medications that reduce acid secretion and are used for treating many conditions such as gastroesophageal reflux disease (GERD), dyspepsia, reflux esophagitis, peptic ulcer disease, and hypersecretory conditions (e.g. Zollinger-Ellison syndrome), and as part of the eradication therapy for Helicobacter pylori bacteria. However, approximately 25% to 70% of people are prescribed a PPI inappropriately. Chronic PPI use without reassessment contributes to polypharmacy and puts people at risk of experiencing drug interactions and adverse events (e.g. Clostridium difficile infection, pneumonia, hypomagnesaemia, and fractures).
  
  
  OBJECTIVE
  To determine the effects (benefits and harms) associated with deprescribing long-term PPI therapy in adults, compared to chronic daily use (28 days or greater).
  
  
  METHODS
  We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10), MEDLINE, Embase, clinicaltrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). The last date of search was November 2016. We handsearched the reference lists of relevant studies. We screened 2357 articles (2317 identified through search strategy, 40 through other resources). Of these articles, we assessed 89 for eligibility.
  
  
  METHODS
  We included randomized controlled trials (RCTs) and quasi-randomized trials comparing at least one deprescribing modality (e.g. stopping PPI or reducing PPI) with a control consisting of no change in continuous daily PPI use in adult chronic users. Outcomes of interest were: change in gastrointestinal (GI) symptoms, drug burden/PPI use, cost/resource use, negative and positive drug withdrawal events, and participant satisfaction.
  
  
  METHODS
  Two review authors independently reviewed and extracted data and completed the risk of bias assessment. A third review author independently confirmed risk of bias assessment. We used Review Manager 5 software for data analysis. We contacted study authors if there was missing information.
  
  
  RESULTS
  The review included six trials (n = 1758). Trial participants were aged 48 to 57 years, except for one trial that had a mean age of 73 years. All participants were from the outpatient setting and had either nonerosive reflux disease or milder grades of esophagitis (LA grade A or B). Five trials investigated on-demand deprescribing and one trial examined abrupt discontinuation. There was low quality evidence that on-demand use of PPI may increase risk of 'lack of symptom control' compared with continuous PPI use (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.31 to 2.21), thereby favoring continuous PPI use (five trials, n = 1653). There was a clinically significant reduction in 'drug burden', measured as PPI pill use per week with on-demand therapy (mean difference (MD) -3.79, 95% CI -4.73 to -2.84), favoring deprescribing based on moderate quality evidence (four trials, n = 1152). There was also low quality evidence that on-demand PPI use may be associated with reduced participant satisfaction compared with continuous PPI use. None of the included studies reported cost/resource use or positive drug withdrawal effects.
  
  
  CONCLUSIONS
  In people with mild GERD, on-demand deprescribing may lead to an increase in GI symptoms (e.g. dyspepsia, regurgitation) and probably a reduction in pill burden. There was a decline in participant satisfaction, although heterogeneity was high. There were insufficient data to make a conclusion regarding long-term benefits and harms of PPI discontinuation, although two trials (one on-demand trial and one abrupt discontinuation trial) reported endoscopic findings in their intervention groups at study end.
authors.affiliation: Department of Pharmacy, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada, K1H 8L6.
authors.forename: Taline A
authors.initials: TA
authors.lastname: Boghossian
authors.affiliation: Department of Pharmacy, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada, K1H 8L6.
authors.forename: Farah Joy
authors.initials: FJ
authors.lastname: Rashid
authors.affiliation: Bruyère Research Institute, University of Ottawa, 43 rue Bruyere St, Room 730D, Ottawa, ON, Canada, K1N 5C8.
authors.forename: Wade
authors.initials: W
authors.lastname: Thompson
authors.affiliation: Bruyère Research Institute, University of Ottawa, 43 rue Bruyere St, Room 730D, Ottawa, ON, Canada, K1N 5C8.
authors.forename: Vivian
authors.initials: V
authors.lastname: Welch
authors.affiliation: Department of Medicine, Division of Gastroenterology, McMaster University, 1200 Main Street West, Room 4W8E, Hamilton, ON, Canada, L8N 3Z5.
authors.forename: Paul
authors.initials: P
authors.lastname: Moayyedi
authors.affiliation: School of Pharmacy, University of Waterloo, 10 Victoria St S., Room 7004, Kitchener, ON, Canada, N2G 1C5.
authors.forename: Carlos
authors.initials: C
authors.lastname: Rojas-Fernandez
authors.affiliation: Bruyère Research Institute, University of Ottawa, 43 rue Bruyere St, Room 730D, Ottawa, ON, Canada, K1N 5C8.|Family Medicine, University of Ottawa, 75 Bruyere St, Ottawa, ON, Canada, K1N 5C8.
authors.forename: Kevin
authors.initials: K
authors.lastname: Pottie
authors.affiliation: Bruyère Research Institute, University of Ottawa, 43 rue Bruyere St, Room 730D, Ottawa, ON, Canada, K1N 5C8.|School of Pharmacy, University of Waterloo, 10 Victoria St S., Room 7004, Kitchener, ON, Canada, N2G 1C5.|Family Medicine, University of Ottawa, 75 Bruyere St, Ottawa, ON, Canada, K1N 5C8.
authors.forename: Barbara
authors.initials: B
authors.lastname: Farrell
mesh_terms: D000368:Aged; D000069340:Deprescriptions; D004941:Esophagitis / Q000188:drug therapy*; D005764:Gastroesophageal Reflux / Q000188:drug therapy*; D006801:Humans; D057970:Inappropriate Prescribing; D008875:Middle Aged; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D054328:Proton Pump Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D028761:Withholding Treatment
chemical_list: D054328:Proton Pump Inhibitors