(P35) Deprescribing Proton Pump Inhibitors: A Quality Improvement Initiative

Objective/Aim: The objective of this study is to identify the baseline rate of prescribed proton pump inhibitors (PPIs) among long-term care (LTC) residents and to safely stop or reduce the dosage of prescribed PPIs in residents without evidenced-based indication for continuation. The target reduction rate is 25% within 12 weeks in order to reduce polypharmacy, pill burden, adverse events and improve quality of life for nursing home residents.

Background: PPIs are commonly prescribed. However, PPI long-term usage can cause adverse effects including community acquired pneumonia, Clostridium difficile-associated diarrhea, impaired vitamin B12 absorption, hypomagnesemia and fractures. Deprescribing PPIs in the LTC setting is essential as this population has some of the highest polypharmacy rates with many residents taking more than 10 medications.

Quality Improvement Methods: The plan, do, study, act (PDSA) approach was used. Residents on PPIs without evidence-based indications according to the American Gastroenterological Association guidelines were identified. From a total of 85 LTC residents in a nursing home in Southeast Michigan, 27 residents were being prescribed a PPI. Five residents were excluded due to history of Barrett's esophagitis, chronic steroid use, severe esophagitis or bleeding with or without PUD. Consent for discontinuation was obtained from 19 residents, legal guardians or power of attorney. Three residents were excluded due to inability to obtain consent.

PPIs were tapered in a standardized method per study protocol. Instructions to assist the residents in sitting up at 60 degrees during and for at least one hour after meals and to administer as needed calcium carbonate for rebound symptoms were added. Residents were monitored at two, four and eight weeks for as needed medication usage and for rebound symptoms such as weight loss, nausea, vomiting, increased agitation and loss of appetite. We will continue to monitor residents for a total of 12 weeks.

Results : Our study sample included 19 residents, 74% identified as female, with a mean age of 86 (range 60-97). Our intervention was stopping or tapering PPI dose per study protocol. Residents have been monitored for eight weeks, PPI was stopped in 17 residents (89%). One resident was not tapered due to requiring as needed calcium carbonate more than half of the days for symptoms of indigestion and one resident was restarted on PPI due to recurrence of reflux symptoms. There have been no reported symptoms of weight loss, nausea, vomiting, increased agitation or loss of appetite thus far.

Conclusions: Our study demonstrates that a PPI deprescribing protocol can be successfully implemented in the nursing home setting to decrease unnecessary medication burden in this vulnerable population. PPIs were discontinued in the majority of the study population with few side effects reported after eight weeks. Ongoing studies on deprescribing will help to further support patient safety and improve the care of older adults in this setting.