Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in VA. Roughly one in six Veterans uses them to ease digestive disorders, such as heartburn or acid reflux. The drugs are effective and well-tolerated when consumed properly.
They are also overused. Studies show that as many as six in 10 PPI prescriptions lack a clear evidence-based indication. Long-term use of the drugs carries a risk of serious side effects, such as pneumonia and bone fractures.
Individual VA pharmacies have been working to lower PPI use for Veterans who do not truly need them. For example, at the Lexington VA Medical Center in Kentucky, pharmacist Kelly Davis says her team’s program has yielded good results.
“The whole facility has bought into it, including our primary care providers. The awareness of the program, coupled with the fact that physicians are seeing more evidence of the risks of long-term PPI therapy, has led providers to be very cautious when prescribing PPIs. As a whole, we’ve found that the program has decreased our unnecessary PPI use.”
National program underway
A national VA program called RaPPID is underway to do the same on a wide scale, and to teach best practices. The acronym stands for the National Randomized Proton Pump Inhibitor De-prescribing program.
The research team is led by Dr. Sameer Saini of the VA Ann Arbor Healthcare System in Michigan, Dr. Loren Laine of the VA Connecticut Healthcare System and Dr. Yu-Xiao Yang of the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.
VA researchers are evaluating the program’s effectiveness. They are working with VA National Pharmacy Benefits Management Services, which is leading RaPPID. The researchers are trying to understand how effective RaPPID has been in improving the use of PPIs and ensuring no negative health consequences, such as peptic ulcer bleeding, have occurred with PPI de-prescribing.
The PPI stewardship team at the Lexington VA (pictured at the top of this blog) has included, from left, internist Dr. Sean Lockwood and pharmacists Kelly Davis and Rachel Hargreaves.
“We’re trying to understand the intended and unintended effects of PPIs and ensure that we maximize the learning opportunity for Veterans and the VA health system,” says Saini. “We hope this evaluation will provide not only valuable insight into the benefits and harms of a national effort to appropriately de-prescribe PPIs, but also broader lessons about how to effectively undertake other programs to de-implement low-value clinical practices in the future.”
PPIs account for more than 11 million 30-day prescriptions each year in VA. The drugs are inexpensive on a per-pill basis. However, their widespread use translates into $50 million in VA annually. Current research suggests patients could stop or reduce the use of the drugs in more than one-third of the cases.