Jacob Kurlander, MD, on Patient Perceptions of PPI Use

It is unknown whether studies on possible adverse effects associated with proton pump inhibitors (PPIs) have impacted patients’ perceptions of PPIs and medication use. A study led by Jacob Kurlander, MD, who is a clinical researcher at University of Michigan Division of Gastroenterology and the VA Ann Arbor Health Care System, sought to determine patients’ level of concern about PPI adverse effects and its association with attempts at discontinuation of treatment.

The researchers surveyed 755 adults with gastroesophageal reflux disease (GERD) on topics that included awareness of and concern about PPI adverse effects, prior discussion with providers, and attempts to stop PPI use due to concerns about adverse effects.

Overall, concern about PPI use was common and strongly associated with attempts at discontinuation. Additionally, individuals at high risk of upper gastrointestinal (GI) bleeding were equally likely to have tried to stop PPI use compared with other patients. For such high-risk patients, PPIs have been recommended to prevent bleeding events.

Gastroenterology Consultant caught up with Dr Kurlander about the research.

Gastroenterology Consultant: What prompted you to conduct your study?

Jacob Kurlander: In clinic, we often get questions from our patients about whether it is safe to continue PPI use after hearing about possible side effects. So, this question about PPI safety anecdotally appeared to be very much on patients’ minds. In addition, we know from some prior studies among physicians that when they are concerned about possible PPI harms, they are more likely to discontinue PPIs when used for prevention of GI bleeding than when used for GERD, contrary to our best evidence about appropriate PPI use. Together, these observations made us wonder how patients perceive PPIs and the associated risks, and whether they are potentially stopping them appropriately, or inappropriately, as a result.

GASTRO CON: Were you surprised by the study findings?

JK: I was not completely surprised by our results. There are headlines in the New York Times to the effect that PPIs are associated with higher mortality. Naturally, these types of stories are going to grab patients’ attention. In terms of patients managing these drugs on their own, I think patients have this idea that because they can get PPIs over the counter, it is safe for them to manage them on their own. However, that is not always the case. For a patient with GERD without any high-risk features, it’s reasonable for a patient to guide their own therapy. On the other hand, for a patient who should be on a PPI to prevent GI bleeding, patients certainly need to consult with their healthcare providers about the wisdom of stopping.

GASTRO CON: In your study, only 24% of patients discussed PPI risks and benefits with a provider. Do you think more discussion is warranted on this topic between providers and patients?

JK: Healthcare providers are extremely busy and have difficulty always providing the anticipatory guidance that they might ideally. At the least, I think for patients on PPIs, healthcare providers would be well served to re-evaluate the need for ongoing use at least once a year. In the case of a patient who definitely needs to continue on PPIs for bleeding prevention, making that clear to the patient is critical.

GASTRO CON: Among patients who had attempted to stop their PPI therapy, most did so without a provider recommendation. How can this negatively impact the patient and how should a gastroenterologist approach this?

JK: The most concerning scenario is when a patient who is on multiple ulcer-causing drugs decides to stop their PPI on their own, which can result in ulcer bleeding, endoscopy, hospitalization, and rarely death. Truth be told, gastroenterologists often only come into contact with these patients after they have bled and are seen in the hospital. To address this issue, we are going to have to involve other specialties, including primary care physicians (PCPs) and cardiologists, who are often the ones prescribing the aspirin, nonsteroidal anti-inflammatory drugs, and anticoagulants that are the main risk factors for bleeding.

GASTRO CON: What are the clinical implications of the study and how can a gastroenterologist apply them to practice?

JK: The main implication is that healthcare providers need to be informed about when it is safe or not to stop a PPI, and that they need to proactively discuss these issues with patients, who may otherwise make suboptimal decisions about their PPIs. On a larger scale, if as gastroenterologists we want to promote the GI health of the population, we need to help create systems that ensure patients are appropriately using PPIs without making PCPs shoulder the full burden. This may require more direct patient engagement at a system level about appropriate PPI use, or strategies such as involving clinical pharmacists.

Reference:

Kurlander JE, Kennedy JK, Rubenstein JH, et al. Patients' perceptions of proton pump inhibitor risks and attempts at discontinuation: a national survey. Am J Gastroenterol. 2019;114(2):244-249. doi: 10.14309/ajg.0000000000000061