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50 CPD ACTIVITY OTC OPTIONS TO HELP PATIENTS REDUCE AND CEASE PPI USE Dr Catherine Panwar Catherine has more than eight years of experience in health communications, with a passion for changing the way people understand health. Since completing her BSc (Hons) and PhD in molecular and biochemical parasitology, Catherine researches and delivers content for consumers and healthcare professionals across a wide variety of health topics. Acknowledgements: Alex Page, Andrew Harris, Brett MacFarlane, John Bell. Disclaimer: Catherine Panwar is the director of Panwar Health which is contracted by Reckitt Benckiser (RB) for medical writing services for Gaviscon. LEARNING OJECTIVES After completing this CPD activity, pharmacists should be able to: • Outline the treatment for gastro- oesophageal reflux disease (GORD). • Describe the options for tapering the dose of proton pump inhibitors (PPIs) and management of mild to moderate GORD symptoms. • Describe the evidence supporting the use of over-the-counter medicines for addressing breakthrough GORD symptoms when taking PPIs. 2016 Competency Standards: 3.1, 3.2, 3.5. Accreditation Number: A2008RP1 (Exp: 31/07/2022). Introduction Proton-pump inhibitors (PPIs) are a highly effective treatment for gastro-oesophageal reflux disease. However, for some patients prescribed high doses for long periods of time there is pressure to regularly reassess the dose and taper if necessary. Rebound acid hypersecretion challenges success of PPI taper, with studies noting limited success of patient education in reducing PPI use. This article considers the evidence for over-the-counter (OTC) treatments with different modes of action in providing additional support for PPI taper. Of the options available, alginate- based treatments show promise in assisting successful PPI deprescribing. Although PPI deprescribing is a priority initiative, OTC treatments are not currently emphasised in PPI taper protocols. New evidence supports the use of alginates for breakthrough symptoms on PPIs and during taper. Clinicians and patients should reconsider the place of alginates at each stage of gastro-oesophageal reflux disease (GORD) management. Treating GORD GORD is a common condition with a high disease burden in the Australian community.1 The most recent guidelines in Australia recommend an initial trial of an antacid, either an antacid plus alginate preparation or magnesium hydroxide plus aluminium hydroxide.2 If antacids do not provide adequate relief, a histamine-2 receptor antagonist (H2RA) or a standard- dose PPI is recommended.2 Standard dose PPIs include:2 • Esomeprazole 20mg. • Lansoprazole 30mg. • Omeprazole 20mg. • Pantoprazole 40mg. • Rabeprazole 20mg. For frequent or severe symptoms, PPIs are the preferred initial therapy.2 A four- to eight-week trial should be followed by a review.2 If symptom control is adequate at review, the dose should be tapered to maintenance therapy or PPI treatment ceased altogether.2 If symptom control is inadequate, the patient’s adherence to their PPI therapy should be checked. Endoscopy to exclude other conditions can be considered for inadequately controlled patients who are adherent to their PPI. A high-dose PPI regimen can be considered if endoscopy has ruled out other conditions. A high-dose PPI regimen ideally involves taking a standard PPI dose twice daily rather than double the standard dose once daily.2 The body of evidence shows PPIs are highly effective medications with a favourable safety profile for short-term use. However, there are emerging reports of potential complications associated with long-term PPI use.3 These include an increase in risk of osteoporotic fractures, enteric infections, pneumonia, dementia, upper gastrointestinal cancer, vitamin and mineral deficiencies, nephritis and RETAIL PHARMACY • AUG 2020 2 CPD CREDITS