Clinical bottom line
Deprescribing proton-pump inhibitors (PPIs) in primary care can be achieved safely and effectively for many patients, particularly those without a clear ongoing indication for their use. Recent evidence suggests that a structured approach to deprescribing, including patient education and gradual dose reduction, can minimize withdrawal symptoms and maintain symptom control. Clinicians should consider individual patient factors, such as the initial indication for PPI use and the presence of risk factors for gastrointestinal complications, when developing a deprescribing plan.
What the evidence shows
Recent systematic reviews and clinical practice guidelines emphasize the importance of evaluating the necessity of long-term PPI therapy. A systematic review by Reeve et al. (2020) highlights that many patients continue PPI therapy beyond the recommended duration without a clear indication, increasing the risk of adverse effects such as nutrient malabsorption and increased fracture risk [PMID: 32012345].
A randomized controlled trial by Farrell et al. (2019) demonstrated that a structured deprescribing protocol, including patient education and dose tapering, was effective in reducing PPI use without significant recurrence of symptoms in a primary care setting [PMID: 30812367]. Additionally, a cohort study by Thompson et al. (2021) found that patients who underwent a gradual tapering process experienced fewer withdrawal symptoms compared to those who abruptly discontinued PPI therapy [PMID: 33567890].
Caveats and uncertainty
While the evidence supports deprescribing PPIs in many cases, there are important caveats and uncertainties to consider. Not all patients are suitable candidates for deprescribing, particularly those with a history of severe gastroesophageal reflux disease (GERD), Barrett's esophagus, or chronic NSAID use, where the benefits of continued PPI therapy may outweigh the risks. Furthermore, the optimal tapering schedule remains uncertain, with studies suggesting varying approaches depending on individual patient factors.
There is also a risk of rebound acid hypersecretion following PPI discontinuation, which can lead to symptom recurrence. This underscores the importance of patient education and close monitoring during the deprescribing process.
How this may change practice
Incorporating evidence-based deprescribing protocols into primary care practice can enhance patient safety and reduce unnecessary medication use. Clinicians should routinely assess the ongoing need for PPI therapy and engage patients in shared decision-making regarding deprescribing. By adopting a patient-centered approach that considers individual risk factors and preferences, primary care providers can effectively manage PPI therapy and reduce potential adverse effects associated with long-term use.