NP Louise Fowler - GP CME
41
NP Louise Fowler Nurse Practitioner WBoP PHO Acute Demand Aged Residential Care Team Tauranga 12:05 - 13:00 WS #27: Falls in The Elderly and PPIs
Transcript of NP Louise Fowler - GP CME
NP Louise FowlerNurse Practitioner
WBoP PHO Acute Demand Aged Residential
Care Team
Tauranga
1205 - 1300 WS 27 Falls in The Elderly and PPIs
Proton Pump Inhibitorrsquos Falls and Fractures in the Elderly
Louise Fowler Nurse PractitionerRN MN PG Cert PrescribingAcute Demand Team ndash Aged Residential Care
Dr Felix Ram ndash Clinical Pharmacologist
Falls
bull 13 of community dwelling residents greater than 65 fall each year
bull Growing number of over 65rsquos
bullNational and international focus
bullCan result in harm
bullMultifactorial
Bumps
Bruises
lacerations
Fractures
Traumatic brain injury
Death
Extrinsic
Intrinsic
bull Footwearbull Lightingbull Rugs
bull Not being clipped onto carabiner
bull Hypotensionbull Parkinsonismbull Dehydrationbull Urinary
frequencybull Infectionbull Effects of
medicationsbull No fear
Angel Falls in Venezuela
Medication Classes Identified with Falls
bull Opioids
bull Anticholinergics
bull Antipsychotics
bull Sedating
bull Long term use of PPIrsquos
For too long we have considered PPIrsquos as being safe
Research Relating to Falls Fractures and PPIs
Review 250000 pts ndash current and prolonged use of PPI has increased risk of falls and fractures
(Anderson Johansen Abrahamsen 2016)
Review 400 elderly woman fell 200 fractures ndash significant risk of falls and fractures on PPIs (fallsOR 192 95 CI 105 to 350 p=004 and fractures OR 215 95 CI 110 to 421 p= 003)
(Thaler et al 2016)
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Proton Pump Inhibitorrsquos Falls and Fractures in the Elderly
Louise Fowler Nurse PractitionerRN MN PG Cert PrescribingAcute Demand Team ndash Aged Residential Care
Dr Felix Ram ndash Clinical Pharmacologist
Falls
bull 13 of community dwelling residents greater than 65 fall each year
bull Growing number of over 65rsquos
bullNational and international focus
bullCan result in harm
bullMultifactorial
Bumps
Bruises
lacerations
Fractures
Traumatic brain injury
Death
Extrinsic
Intrinsic
bull Footwearbull Lightingbull Rugs
bull Not being clipped onto carabiner
bull Hypotensionbull Parkinsonismbull Dehydrationbull Urinary
frequencybull Infectionbull Effects of
medicationsbull No fear
Angel Falls in Venezuela
Medication Classes Identified with Falls
bull Opioids
bull Anticholinergics
bull Antipsychotics
bull Sedating
bull Long term use of PPIrsquos
For too long we have considered PPIrsquos as being safe
Research Relating to Falls Fractures and PPIs
Review 250000 pts ndash current and prolonged use of PPI has increased risk of falls and fractures
(Anderson Johansen Abrahamsen 2016)
Review 400 elderly woman fell 200 fractures ndash significant risk of falls and fractures on PPIs (fallsOR 192 95 CI 105 to 350 p=004 and fractures OR 215 95 CI 110 to 421 p= 003)
(Thaler et al 2016)
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Falls
bull 13 of community dwelling residents greater than 65 fall each year
bull Growing number of over 65rsquos
bullNational and international focus
bullCan result in harm
bullMultifactorial
Bumps
Bruises
lacerations
Fractures
Traumatic brain injury
Death
Extrinsic
Intrinsic
bull Footwearbull Lightingbull Rugs
bull Not being clipped onto carabiner
bull Hypotensionbull Parkinsonismbull Dehydrationbull Urinary
frequencybull Infectionbull Effects of
medicationsbull No fear
Angel Falls in Venezuela
Medication Classes Identified with Falls
bull Opioids
bull Anticholinergics
bull Antipsychotics
bull Sedating
bull Long term use of PPIrsquos
For too long we have considered PPIrsquos as being safe
Research Relating to Falls Fractures and PPIs
Review 250000 pts ndash current and prolonged use of PPI has increased risk of falls and fractures
(Anderson Johansen Abrahamsen 2016)
Review 400 elderly woman fell 200 fractures ndash significant risk of falls and fractures on PPIs (fallsOR 192 95 CI 105 to 350 p=004 and fractures OR 215 95 CI 110 to 421 p= 003)
(Thaler et al 2016)
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
bullNational and international focus
bullCan result in harm
bullMultifactorial
Bumps
Bruises
lacerations
Fractures
Traumatic brain injury
Death
Extrinsic
Intrinsic
bull Footwearbull Lightingbull Rugs
bull Not being clipped onto carabiner
bull Hypotensionbull Parkinsonismbull Dehydrationbull Urinary
frequencybull Infectionbull Effects of
medicationsbull No fear
Angel Falls in Venezuela
Medication Classes Identified with Falls
bull Opioids
bull Anticholinergics
bull Antipsychotics
bull Sedating
bull Long term use of PPIrsquos
For too long we have considered PPIrsquos as being safe
Research Relating to Falls Fractures and PPIs
Review 250000 pts ndash current and prolonged use of PPI has increased risk of falls and fractures
(Anderson Johansen Abrahamsen 2016)
Review 400 elderly woman fell 200 fractures ndash significant risk of falls and fractures on PPIs (fallsOR 192 95 CI 105 to 350 p=004 and fractures OR 215 95 CI 110 to 421 p= 003)
(Thaler et al 2016)
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Medication Classes Identified with Falls
bull Opioids
bull Anticholinergics
bull Antipsychotics
bull Sedating
bull Long term use of PPIrsquos
For too long we have considered PPIrsquos as being safe
Research Relating to Falls Fractures and PPIs
Review 250000 pts ndash current and prolonged use of PPI has increased risk of falls and fractures
(Anderson Johansen Abrahamsen 2016)
Review 400 elderly woman fell 200 fractures ndash significant risk of falls and fractures on PPIs (fallsOR 192 95 CI 105 to 350 p=004 and fractures OR 215 95 CI 110 to 421 p= 003)
(Thaler et al 2016)
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Research Relating to Falls Fractures and PPIs
Review 250000 pts ndash current and prolonged use of PPI has increased risk of falls and fractures
(Anderson Johansen Abrahamsen 2016)
Review 400 elderly woman fell 200 fractures ndash significant risk of falls and fractures on PPIs (fallsOR 192 95 CI 105 to 350 p=004 and fractures OR 215 95 CI 110 to 421 p= 003)
(Thaler et al 2016)
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
PPIs
FracturesFalls
Walking up Angel falls
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
PPIs
FracturesFalls
Walking up Angel falls
Reduced BMD
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
PPIs
FracturesFalls
Walking up Angel falls
Timed up and goRhombergs
(Lewis et al 2014)
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
PPIs also linked with increased risk of
bull Acute interstitial nephritis
bull Chronic kidney disease
bull Community acquired pneumonia
bull Clostridium Difficile
bull Vitamin B12 deficiency
bull Magnesium deficiency
bull Bowel cancer
Behind Angel falls
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
bull Early 90rsquos special authority through hospital pharmacy
2017 ndash purchased from community pharmacy
Number of New Zealanders prescribed PPIs
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Medsafe -Guidelines for OmeprazoleIndication Dose Recommended
duration of therapyMaintainance therapy
Reflux oesophagitis
Severe reflux oesophagitis
20mg once daily
40mg once daily
4 weeks
8 weeks
10mg daily
Duodenal ulcer 20mg once daily 2 weeks 10mg once daily
NSAID associated lesions
Prevention of NSAID associated lesions
20mg once daily
20mg once daily
4 weeks Duration of NSAID
Acid related dyspepsia 10-20mg once daily 2-4 weeks If symptoms not resolved after 4 weeks consider further investigation
Zollinger-Ellisons syndrome 60mg once daily 90 maintained on 20-120mg
(Medsafe - datasheet omeprazole 2014)
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Optimal treatment
Table top mountain above Angel falls
bull Lowest dosebull Shortest duration
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Rebound Acid Secretion
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
53 year old man
bull Farmer on omeprazole for 2-3 months for indigestion and was needing higher dose and was taking it more regularly up to twice daily
bull His wife was an awesome GP and suggested he try to stop omeprazole and just take acidex
His story
bull ldquoLife was hell It was so hard to get off that stuff I will never go on it againrdquo
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Medscape ndashDeprescribing PPIrsquos
Deprescribing definition
Stopping stepping down or reducing doses
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Deprescribing PPIs
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Discontinuing PPIsOne Aged Care facility
Canadian Rest home 150 bed facility41 residents on a PPI28 residents fitted criteria for discontinuation27 had PPI discontinued 19 (70) symptom free after 8 weeks (Lee et al 2017)
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
NHS ndash Protocol
bull Indications for PPIrsquosbull Lifestyle modifications
bull Doses and length of treatment
bull Prophylaxis use due to medications (are these meds necessary)bull NSAID
bull Aspirin
bull Immunosuppression therapy
bull Medication review processbull There will be a small percentage not appropriate to stop
bull Stepping down PPI
bull Stopping PPI and other drugs
McGinn (2015) NHS polypharmacy medicines review project
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
BPAC
Discuss with patient expectations short term
Prescribe for 4-6 weeks ndash no repeats
40 people rebound secretion ndash discuss possibility
Halve strength for 2 weeks
Stop PPI with PRN ndashand antacid plus foaming agent eg Mylanta P oral liquid or acidex
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Case study- 92 year old lady -Polypharmacy prescribing
cascade
Background information
92 year old lady living in ARC having had multiple falls recently
Hx of presenting illness
Recent hyporsquos hip and leg pain She was bedbound and poor oral intake
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
On Examination
bull Lying in bed ndash not been up for 2 days
bull Obeying commands
bull Lethargic
bull Chest Normal breath sounds
bull Cardiac HR 48 Apical BP 9560 S1 and S2 no extra heart sounds no elevated JVP no peripheral oedema
bull Musculoskeletal Painful legs back and hips (Naproxen added)
Wt 45kg
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Medical History
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 36mmolL 4 weeks prior
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Med Hx
bull Vascular Dementia
bull Ischaemic Heart Disease
bull Cardiomyopathy
bull Type 2 Diabetes ndash on insulin
bull Osteo-arthritis
bull Hypertension
bull Gout
bull Hip pain
Medications
bull Simvastatin 80mg
bull Digoxin 625 mcg
bull Trimethoprim
bull Carvedilol 25mg BD
bull Enalapril 25mg BD
bull Frusemide 20mg BD
bull Naprosyn 250mg OD (3 weeks)
bull Paracetamol 1g Q4H
bull Omeprazole 20mg OD (years)
bull Lantus 20 units mane
bull Novorapid 6 units with meals
bull Ibuprofen 400mg TDS - PRN
Bloods eGFR 17 dropped from 36mlmin 4 weeks prior Creatinine 221LFTrsquos Alk Phos ndash 187 GGT ndash 208 Potassium = 59 HbA1c March 92mmolL in October 58 Digoxin levels - elevated
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Impression
bull Myalgia ndash secondary to high dose Simvastatin
bull Hypoglycaemiabull Secondary to anorexia
bull Secondary to acute renal failure and accumulation of insulin
bull Hypotension
bull ARFbull Secondary to triple whammy
bull Secondary to hypotension
bull Bradycardia
bull Hyperkalaemia
bull Potential for Digoxin toxicity
bull Omeprazole no obvious long term indication
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
PlanEducation to staffConsult with Clinical Pharmacist and GPRecommendations madebull Changed insulin regimen
bull Stop bolus insulin bull Reduce basal by 10
bull Stop Naprosyn and Ibuprofenbull Stop frusemide - PRNbull Rationalised medication
bull Stop Simvastatin digoxin Omeprazole
bull Repeat kidney function
10 days later her eGFR 37 body pain had gone and she was walking her visitors outside
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Take home messages
bull Start low fixed duration
bull Review long term PPIrsquos
bull Deprescribe
bull Both in dose and frequency
bull Rebound acid secretion ndash 2 weeks
bull Add antacid ndash mylanta acidex
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Disclosure
bull I disclose that I have no commercial interest in this presentation and it was prepared purely as a result of patient concern and personal interest
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Contact
bull Louise Fowler NP louisefwbopphoorgnz
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
Questions
OR
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
References
bull Adams A Black M Zhang J Shi J Jacobsen S Proton-pump inhibitor use and hip fractures in men a population-based case-control study Annals of Epidemiology (2014 Apr) 24(4) 286-290
bull Andersen B Johansen P Abrahamsen B Proton pump inhibitors and osteoporosis Current Opinion in Rheumatology (2016 July) 28(4) 420-425
bull Cai D Feng W Jiang Q Acid-suppressive medications and risk of fracture an updated meta-analysis International Journal of Clinical and Experimental Medicine (2015 Jun) 158(6)8893-904 eCollection 2015
bull Cea Soriano L Ruigoacutemez A Johansson S Garciacutea Rodriacuteguez LA Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting Phramacotherapy (2014 Jun) 34(6)570-81 doi 101002phar1410
bull McGinn D Protocol for prescribing proton-pump inhibitors initiation review and discontinuation UK NHS (2015 April) httpwwwmedicinesoptimisationacademycomwp-contentuploads201504Protocol-for-prescribing-PPIspdf
bull Farrell B Pottie K Thompson W Boghossian T Pizzola L Rashid F J hellip Moayyedi P (2017) Deprescribing proton pump inhibitors Evidence-based clinical practice guideline Canadian Family Physician 63(5) 354ndash364
bull Lee C Lo A Ubhi K amp Milewski M (2017) Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site Quality Improvement Project The Canadian Journal of Hospital Pharmacy 70(3) 215ndash223
bull Fowler L amp Ram F (2017) Are PPIs increasing the risk of falls and fractures in our elderly population A prescription for concern and time to act on the evidence Logic 16(1)22-27 accessed from httpsviewjoomagcomlogic-no-1-march-20170297368001490305120short
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
bull Zhou B Huang Y Li H Sun W Liu J Proton-pump inhibitors and risk of fractures an update meta-analysis Osteoporosis International (2016 January) 27(1)339-47
bull Yang YX Lewis JD Epstein S Metz DC Long-term proton-pump inhibitor therapy and risk of hip fracture Journal of the American Medical Association (2006 Dec) 27 296(24)2947-53
bull Thaler H Sterke C Van Der Cammen T Association of proton pump inhibitor use with recurrent falls and risk of fractures in older women A study of medication use in older fallers Journal of Nutrition Health amp Aging (2016 Jan) 20(1) 77-81 doi101007s12603-016-0679-0
bull Targownik LE1 Leslie WD Davison KS Goltzman D Jamal SA Kreiger N JosseRG Kaiser SM Kovacs CS Prior JC Zhou W CaMos Research Group The relationship between proton pump inhibitor use and longitudinal change in bone mineral density a population-based study from the Canadian Multicentre Osteoporosis Study (CaMos) Gastroenterology (2010) 138896-904
bull New Zealand data sheet - Omeprazole (2014 January 13) In Medsafe Retrieved from httpwwwmedsafegovtnzprofsdatasheetoOmeprazole20mgcappdf
bull Ding J Heller D Ahern F Brown T The relationship between proton pump inhibitor adherence and fracture risk in the elderly Calcified Tissue International (2014 June) 94(6) 597-607
bull Kwok CS Yeong JK Loke YK Meta-analysis risk of fractures with acid-suppressing medication Bone (2011 Apr) 1 48(4)768-76 doi 101016jbone201012015
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
News release 6618 Medscape
bull Up to 40 of patients with reflux symptoms treated with PPIs deal with persistent symptoms and there are few treatment options for this group Spechler told the crowd of about 1800 people here at Digestive Disease Week 2018
bull We have to get out of the mindset that theres nothing we can do for these patients he told Medscape Medical News Weve been doing our patients somewhat of a disservice by not recommending reflux surgery when appropriate
