Do not continue prescribing long term proton pump inhibitor (PPI) medication to patients without attempting to reduce the medication down to the lowest effective dose or cease the therapy altogether
While proton pump inhibitors (PPIs) are effective drugs for the treatment of gastroesophageal reflux disease (GERD), their use has been linked to increased risk of fractures, pneumonia, enteric infections, vitamin and mineral deficiencies, and acute interstitial nephritis, particularly among older people who make up the largest proportion of PPI users. While there is insufficient evidence to establish causation, these reports deserve consideration when prescribing long term PPI use. This is especially because some patients may be able to stop PPI use immediately after the initial course of therapy without experiencing symptoms. Even though GERD is often a chronic condition, over time the disease may not require acid suppression and it is important that patients do not take drugs that are no longer necessary.
- Choudhry MN, Soran H, Ziglam HM. Overuse and inappropriate prescribing of proton pump inhibitors in patients with Clostridium difficile-associated disease. QJ Med 2008;101:445-8.
- Hollingworth S, Duncan EL, Martin JH. Marked increase in proton pump inhibitors use in Australia. Pharmacoepidemiol Drug Saf 2010;19:1019-24.
- National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline 2014.
The Gastroenterological Society of Australia (GESA) initially engaged its members through its regular online communications, sharing the aims of the EVOLVE initiative, as well as background information on the US and Canadian versions of Choosing Wisely. Members were provided with a copy of the five recommendations made by the American Gastroenterology Association. GESA also consulted externally, with the EVOLVE Lead Fellow addressing the GUT club and the Inflammatory Bowel Disease Group on the initiative. All members of GESA were invited to submit proposed items for the Top 5 list. The GESA Council reviewed all items before reaching consensus on the recommended final list. A review of the evidence for the shortlisted items was then undertaken and the final list and its rationales were signed off by the GESA Council in May 2016.
- 1 Do not repeat colonoscopies more often than recommended by the National Health and Medical Research Council (NHMRC) endorsed guidelines
- 2 Do not undertake faecal occult blood testing in patients who report rectal bleeding, or require investigation for iron deficiency or gastrointestinal symptoms
- 3 Do not continue prescribing long term proton pump inhibitor (PPI) medication to patients without attempting to reduce the medication down to the lowest effective dose or cease the therapy altogether
- 4 Do not undertake genetic testing for coeliac genes as a screening test for coeliac disease
- 5 Do not perform a follow-up endoscopy less than three years after two consecutive findings of no dysplasia from endoscopies with appropriate four quadrant biopsies for patients diagnosed with Barrett’s Oesophagus.