Multidisciplinary Indian Consensus for Rationalizing the Use of Acid Suppressants in Children and Adults: Key Takeaways from CONFOR CONSENSUS

A Multidisciplinary Consensus for Rationalizing the Use of Acid Suppressants in Children and Adults: CONFOR CONSENSUS has been recently published in the June 2024 issue of Euroasian Journal of Hepato-Gastroenterology, an official journal of Euroasian Gastroenterological Association.

CONFOR is a CONsensus among multidisciplinary team (MDT) of healthcare professionals involving gastroenterologists, hepatologists, pediatric gastroenterologists, pediatricians, otolaryngologists, cardiologists, nephrologists, gynecologist, and orthopedists. 1st time a Multidisciplinary panel of doctors provided 21 consensus statements & recommendations for optimizing use of acid suppressants primarily PPIs and provided a simplified deprescribing algorithm.

The CONFOR consensus recommends that when safer alternatives like H2RAs (e.g., ranitidine, famotidine) and antacids are available; PPIs should not be prescribed as 1st line treatment option for on-demand use / in patients who have non-specific abdominal pain or in acute cases of nausea & vomiting.

Multiple studies have documented that in nearly half of the cases, PPIs are prescribed inappropriately and more than 80% of the studied patients had no documented indications for PPI use.

Using a modified Delphi process with multi-disciplinary team of experts, the consensus included statements based on evidence and clinical considerations, and these recommendations were further classified as strong, conditional, or weak.

Some of the key best practice consensus statements include:

• PPIs should not be used as 1st line treatment option in special populations like pregnant women & pediatric patients less than one year of age, especially when safer alternatives like ranitidine are available. Overuse of AST in the pediatric population, including infants, is a growing concern which warrants careful consideration of its use in this special population.
• Experts strongly recommended against routine co-prescription of PPIs for prophylaxis with commonly used drugs like antibiotics, iron preparations, corticosteroids, NSAIDs etc., which are likely to cause GI disturbances.
• Patients with persistent night-time symptoms, bedtime H2RAs like ranitidine or famotidine should be considered.
• 80% of experts strongly recommended that PPI therapy should be stopped / deprescribed once symptoms resolve and On-demand use of H2RAs like ranitidine or famotidine can be considered, if needed. All patients taking PPI should undergo a regular review of the ongoing indications for use.
• The MDT of doctors also strongly agreed that PPIs, compared to H2RAs, increase the risk of dysbiosis, bone fractures, GI, and non-GI infections in both children and adults & when used concomitantly with NSAIDs it might also increase the risk of Acute kidney injury.

PPIs should only be prescribed if clearly indicated to minimize the associated adverse effects and complications. Also, the multidisciplinary expert panel formulated a simplified PPI deprescribing algorithm which emphasizes the necessity of carefully evaluating the indications for continued PPI therapy or deprescribing, accounting for their appropriate and inappropriate use. These recommendations shall enhance the understanding and offer guidance regarding the judicious use of acid suppressants amongst primary care practitioners for better patient outcomes and reduce overall healthcare costs.

Adapted from:

Prabhoo RY, Pai UA, Wadhwa A, Pillai BV, D'souza C, Wadhawan M, Bhatnagar M, Prabhoo MR, Shetty S, Seshadri VP, Bhatnagar S, Manchanda SC, Kher V. Multidisciplinary Consensus for Rationalizing the Use of Acid Suppressants in Children and Adults: CONFOR. Euroasian J Hepatogastroenterol 2024; 14 (1):99-119.