2025 Southeastern Residency Conference

Title: Implementing a Pharmacist Driven Proton Pump Inhibitor (PPI) Deprescribing Intervention in a Veteran Patient Population
Authors: Kristin Allen, Marisa Strychalski, Kye Grooms

Background: 
Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in the VA to treat acid-related stomach disorders. The American College of Gastroenterology (ACG) recommends up to an 8-week course of a PPI for symptomatic relief of gastroesophageal reflux disease (GERD). The PPI should then be tapered off and discontinued or switched to a histamine 2 receptor antagonist (H2RA) for maintenance therapy. The long-term use of PPIs can potentially lead to adverse events such as osteoporosis and bone fractures. Due to these potential long-term risk, they are also included on the American Geriatric Society (AGS) Beers Criteria for potentially inappropriate medication use in older adults. Furthermore, Veterans on long-term PPIs with a low BMI (defined as a BMI of 19 kg/m2 and lower) are at even higher risk of osteoporosis and bone fractures, as low BMI is an independent risk factor in and of itself. The purpose of this study was to limit the potentially inappropriate continuation of formulary PPIs in a geriatric Veteran patient population most vulnerable to developing or worsening osteoporosis by reducing the PPI dose, stopping the PPI, and/or switching to a formulary preferred H2RA.

Methods:  
A data query identified geriatric Veterans (>75 years old) who have an active prescription for omeprazole or pantoprazole for at least 2 years and had at least one of the following: a low BMI, a diagnosis of osteoporosis, or were on osteoporosis prevention/treatment in the last 2 years. Veterans who were deemed appropriate for intervention based on chart review were contacted by phone. Through shared decision-making, the Veteran either continued the PPI at their current dose, reduced the dose, discontinued the PPI, and/or switched to an H2RA and were then scheduled for telephone follow-up for any interventions made. The primary endpoint was the percent difference in PPI utilization following pharmacist intervention. The secondary endpoint was the difference in the total daily dose of the PPI and H2RA for all patients on therapy following pharmacist intervention. The tertiary endpoint was to determine if the results of the DEXA scans performed show new/clinically relevant findings and require intervention. Data collected also included baseline characteristics such as age, weight (in kilograms), body mass index, serum creatinine, sex, and if the patient had a DEXA scan on file with the VA. 

Results:
25 patients were contacted and 72% of patients agreed to the deprescribing intervention. The utilization of low dose PPIs and high dose PPIs decreased by 8% and 24% and the utilization of as needed famotidine and non-pharmacologic strategies increased by 24% and 8% following pharmacist intervention. In total, 20% of Veterans were able to de-escalate PPI therapy and 32% were able to successfully discontinue the PPI and switch to as needed famotidine or non-pharmacologic strategies only. The total daily dose of PPIs decreased by 370 mg and the famotidine dose increased by 120 mg in total across 25 patients. One patient was started on a non-formulary PPI due to uncontrolled GERD symptoms on the formulary agents. Three out of four DEXA scans showed osteopenia/osteoporosis and two patients were started on treatment while one was referred to Endocrinology for further management.

Conclusion:
The pharmacist driven deprescribing intervention was able to de-escalate and discontinue PPI therapy, reduce the total daily dose of PPIs, increase the total daily dose of famotidine, and initiate osteopenia/osteoporosis treatment in those with new/clinically relevant DEXA scan results which illustrates the important role pharmacist play in reducing the risk of adverse drug events and pill burden as well as improving the overall health of the geriatric Veteran patient population.