2024 CONFOR Consensus: Rationalizing Use of Acid Suppressants in Children and Adults

Concern about the inappropriate use of proton pump inhibitors (PPIs) has been rising, with studies showing a lack of ongoing indication for PPI treatment in as many as 50% of patients under the care of general practitioners and approximately 57% among hospitalized patients. A new consensus paper has been published that aims to help clinicians make decisions about when and how to safely deprescribe PPIs and appropriately prescribe acid suppressant therapy (AST) in routine clinical practice.

Proton pump inhibitors (PPIs) should not be prescribed without a definitive indication or as the first line in patients with non-specific abdominal pain or for on-demand use when safer alternatives like H2RAs (e.g., Ranitidine) and antacids are available, says an updated Indian consensus statement.

The CONsensus among the multidisciplinary panel of healthcare professionals FOR rationalizing and deprescribing acid suppressants in children and adults (CONFOR) is the result of the three-step modified Delphi polling process, which developed a valuable resource for primary healthcare professionals. The consensus brought together healthcare professionals across 13 medical specialties, including gastroenterologists, hepatologists, pediatric gastroenterologists, pediatricians, otolaryngologists, cardiologists, nephrologists, gynaecologists, and orthopedists managing patients with acid peptic disorders; that was published in the latest issue of Euroasian Journal of Hepato-Gastroenterology, an official journal of Euroasian Gastroenterological Association.

The participating experts had a virtual meeting followed by a physical meeting and reached preliminary consensus statements after a comprehensive review of scientific literature on clinical trials, cohort studies, systemic reviews and meta-analyses, expert consensus papers, and professional society guidelines on the relevant subjects. For each proposed consensus statement, all members of the multidisciplinary group voted on a 5-point Likert scale (ranging from “strongly agree” to “strongly disagree”) using an electronic voting platform. During the Delphi polling, statements for which at least 75% of the experts collectively voted “strongly agree” or “agree” were considered to have achieved consensus and were accepted to be included in the consensus paper without further deliberation. Statements that received at least 75% of the experts' combined votes of "strongly agree" or "agree" during the Delphi polling were deemed to have reached a consensus.

Tables 1 and 2 summarize the inappropriate use of PPI and side effects associated with AST (especially PPIs) in adults and children.

Table 1: Inappropriate use of PPI in adults and children

Table 2: Summary of well-documented side effects associated with ASTs (especially PPIs) in adults and children

Below are the key statements achieved through this scientific consensus:

Key Statements on Appropriate Use of Acid Suppressants

• One of the major changes involved is that PPI should not be prescribed as a first-line treatment option in patients who have non-specific abdominal pain/for on-demand use when safer alternatives like H2-receptor antagonists (H2RAs) [e.g., Ranitidine, Famotidine] and antacids are available. (Level of Agreement-100%, Strength of Expert Opinion-Strong)
• PPI also should not be prescribed as a first-line treatment option in special populations like pregnant women experiencing heartburn and pediatric patients less than one year of age, when safer alternatives like H2-receptor antagonists (H2RAs) [e.g., Ranitidine, Famotidine] and antacids are available. (Level of Agreement-100%, Strength of Expert Opinion-Strong)
• The panel recommended against routine use of PPI in acute cases of nausea and vomiting in cases unrelated to Gastroesophageal Reflux Disease (GERD). (Level of Agreement-100%, Strength of Expert Opinion-Conditional)
• PPI need not to be prescribed routinely in all patients taking drugs like aspirin/clopidogrel/non-steroidal anti-inflammatory drugs (NSAIDs)/steroids/oral anticoagulants as a monotherapy, who are at low risk for GI bleeding. (Level of Agreement-100%, Strength of Expert Opinion-Conditional)
• As well as the co-prescription for prophylaxis with commonly used drugs like antibiotics/iron preparations/calcium antagonists/corticosteroids/NSAIDs, etc., which are likely to cause GI disturbances. (Level of Agreement-100%, Strength of Expert Opinion-Strong)
• Routine PPI prescriptions in anemia patients without evidence of GI bleeding should be discouraged. (Level of Agreement-100%, Strength of Expert Opinion-Strong)
• The panel suggested the use of bedtime H2RAs like Ranitidine or Famotidine in patients with persistent night-time symptoms with PPI therapy. (Level of Agreement-100%, Strength of Expert Opinion-Strong)
• The panel agreed to prescribe PPIs cautiously in cases like inflammatory bowel disease (IBD), microscopic colitis, spontaneous bacterial peritonitis, and fundic gland polyps, and routine prescription in patients with dual/triple antithrombotic drugs for 8–12 weeks; long-term treatment is to be considered only if patients are at high risk for GI bleeding. (Level of Agreement-100%, Strength of Expert Opinion-Conditional)

Key Statement on Deprescribing Proton Pump Inhibitors (PPIs)

• The consensus strongly recommends deprescribing PPIs in patients without a definitive indication and stepping down to once daily from twice daily in patients with an indication for long-term PPIs. In patients who have completed a course of PPI treatment, resulting in the resolution of symptoms, PPI therapy should be stopped, and on-demand use of H2RAs like Ranitidine/Famotidine may be considered as clinically needed. (Level of Agreement-100%, Strength of Expert Opinion-Strong)

Figure 1: Proton pump inhibitors deprescribing algorithm. Adapted from Prabhoo RY, Pai UA, Wadhwa A, et al.  Euroasian J Hepato- Gastroenterol 2024;14(1):99–119.

 Key Statements Pertaining to the Safety and Monitoring of Acid Suppression Therapy (AST)

• The consensus document noted that PPI increases the risk of dysbiosis, GI, and non-GI infections in children and adults. Daily long-term treatment with AST, especially PPIs, raised the risk of vitamin (B12 and D) and mineral deficiencies (calcium, iron, and magnesium). It further added that long-term PPI use increased the risk of adverse cardio-renal outcomes, including acute kidney injury (AKI); prolonged PPI use may be associated with an increased risk of fractures as compared with H2RAs. (Level of Agreement-100%, Strength of Expert Opinion-Strong)
• The panel strongly advised avoidance of long-term PPI use (>12 weeks) in all patients with liver cirrhosis, chronic kidney disease (CKD), and cardiovascular disease (CVD) and monitoring patients on drugs (e.g., ketoconazole, cefpodoxime, atazanavir, calcium, iron salts, etc.) with pH-dependent absorption and PPI co-medication, considering the possible drug-drug interactions. (Level of Agreement-100%, Strength of Expert Opinion-Strong)

This consensus paper demonstrates the optimal use of acid suppressants, particularly proton pump inhibitors (PPIs), in children and adults based on clinical practice. The consensus statements will also enhance knowledge and provide direction on the prudent use of acid suppressant therapy to improve patient outcomes.

Reference:

Prabhoo RY, Pai UA, Wadhwa A, et al. Multidisciplinary Consensus for Rationalizing the Use of Acid Suppressants in Children and Adults: CONFOR. Euroasian J Hepato- Gastroenterol 2024;14(1):99–119.