Rationalising proton pump inhibitors in palliative care
Follow the principles of medication rationalisation when rationalising proton pump inhibitors (PPIs) in palliative care.
PPIs are used for a variety of indications in patients with palliative care needs including dyspepsia, gastro-oesophageal reflux disease (GORD), peptic ulcer disease (eg Helicobacter pylori eradication therapy, prevention or treatment of ulcers caused by nonsteroidal anti-inflammatory drugs [NSAIDs]).
For most indications (eg GORD, NSAID-induced ulcers), the duration of therapy is about 8 weeks—see the Gastrointestinal guidelines for recommended durations of therapy. For patients taking PPI therapy without a definitive indication, consider deprescribing. Either abruptly stop PPIs, or decrease the dose by halving the daily dose or dosing on alternate days until stopped or the lowest effective dose is reached. Depending on the indication, consider switching to as-required therapy (ie take only on days when symptoms occur).
For patients at high risk for upper gastrointestinal bleeding, complicated gastro-oesophageal disease (eg cancer, Barrett oesophagus, strictures) or idiopathic pulmonary fibrosis, it is often useful to continue PPI therapy to the last days of life. If the patient is unable to swallow, consider continuing therapy by an alternative route.