Inside: Proton Pump Inhibitors (PPIs): To Use or Not to Use? (continued) Page 2 Schwarting Senior Symposium 2017 Register Today! Page 3 Membership Networking Event Page 4 Notes ‘n Votes— January 2017 Page 5

Proton Pump Inhibitors (PPIs): To Use or Not to Use? Bennett Doughty, Pharm.D., Amber Rollins, Pharm.D., Alyssa Taqi, Pharm.D. PGY-1 Pharmacy Practice Residents, VA Connecticut Healthcare System

1 | Spring 2017 CT-ASCP Chapter Newsletter

Proton pump inhibitors (PPIs) have emerged as one of the most commonly prescribed medication classes on the market today. Known for potently suppressing gastric acid secretion, these medications have become a mainstay for the treatment of acid-related gastrointestinal disease and are readily available in most healthcare settings. The FDA has approved PPIs for use in healing of erosive esophagitis (EE), maintenance of healed EE, risk reduction for gastric ulcer (GU) associated with nonsteroidal anti-inflammatory drugs (NSAIDs), Helicobacter pylori (H. pylori) eradication, pathological hyper-secretory conditions, treatment of duodenal ulcers, and gastroesophageal reflux disease (GERD). While proven very effective for managing excessive gastric acid secretion, many patients rely on these medications to provide long-term relief, as PPIs were previously thought to be relatively benign. However, with an increasing amount of evidence demonstrating the risks associated with long-term PPI use, clinicians are being cautioned to review the appropriate use of PPIs and to only use them when clinically indicated. Downfalls of Proton Pump Inhibitors Recent literature has raised concerns regarding the long-term use of PPIs. These effects include but are not limited to decreased absorption of essential nutrients, infection, dementia, fractures, and chronic kidney disease. Malabsorption: Absorption of calcium, iron, and vitamin B12 may be reduced during PPI therapy as these elements rely on an acidic environment for their absorption. While most patients using PPIs for short periods of time will not require supplementation it may be required in the setting of long term use1. Of note, calcium citrate is generally recommended as a first line agent for calcium supplementation, as its absorption is less affected by gastric pH6.

Infection: Acid functions in the stomach to break down food while also killing bacteria. Increased pH levels allow for excess bacterial growth within the stomach. This may result in a change and even an increase in gastrointestinal and respiratory flora. Use of a PPI as short as seven days can increase the risk of infections2. Interestingly, hospitalized patients have been found to be at a higher risk of pneumonia when using PPIs compared with outpatients. Rates of clostridium difficile have been found to be twice as high in patients using PPIs3.

Dementia: Several factors may help explain the potential risk of long term PPI use and dementia. Cognitive impairment is thought to be associated with the reduction in B12 absorption seen in long term PPI use. Proton pump inhibitors may also increase the development of beta-amyloid plaques in the brain, a common pathophysiologic change observed in Alzheimer’s disease4.

Chronic Kidney Disease (CKD): Long term use of PPIs may be associated with an increased risk of developing CKD. Studies have hypothesized that increased risk may be precipitated by recurrent acute kidney injury, or by hypomagnesemia, both of which have been associated with PPIs and incidence of CKD.

Fracture and Osteoporosis: As discussed above, PPI use can decrease absorption of calcium. This may lead to an increased risk of fractures and/or osteoporosis for patients using PPIs for extended periods of time. While PPIs have not been shown to have a conclusive relationship with bone mineral density vitamin D and calcium supplementation is encouraged in patients at high risk for osteoporosis using PPIs.

CT-ASCP's

SenioRx Care Perspective

Spring 2017 Volume XIII No. 3

2 | Spring 2017 CT-ASCP Chapter Newsletter

Discontinuation of PPIs For those patients in which PPI therapy discontinuation is desired, many elements must be considered. Abrupt discontinuation of a PPI can result in rebound GERD symptoms, including acid reflux, nausea, and chest pain. These symptoms may present due to a proliferation of parietal cells in response to suddenly removing the inhibitory mechanism of PPIs. This upregulation causes excess gastric acid secretion in most patients, leading to this uncomfortable return of symptoms7. A systematic taper of PPIs is less likely to result in rebound GERD symptoms. As shown in Image 1, those patients on higher daily doses of PPIs (i.e. omeprazole 40mg or greater, pantoprazole 80mg or greater, etc.) may first half the dose of the medication for approximately one to two weeks (i.e. twice daily dosing stepped down to once daily or 40mg decreased to 20mg). After about one to two weeks at this lower dose, the patient may again be advised to take half the dose for an additional one to two weeks if not at the lowest dose once daily for the specific PPI (i.e. omeprazole 20mg daily). Once the lowest one time dose is reached, the patient may transition to every other day dosing for approximately two weeks. Alternatively, patients may be transitioned to an H2 Receptor Antagonist (H2RA), such as famotidine for two to four weeks. After two to four weeks of every other day dosing or H2RA therapy, the patient should be counseled to stop the medication altogether7. If at any time the patient begins to feel some degree of stomach upset, ‘on demand’ dosing with an H2RA, such as ranitidine, or an antacid, such as calcium carbonate, may be utilized while tapering the PPI. Other ways to avoid these symptoms include removing trigger foods from the patient’s diet, such as caffeine, alcohol, fatty foods, acidic foods, and spicy food7. Eating smaller portions at a slower pace may also decrease stomach pains and nausea. Finally, a probiotic may be recommended for the patient to rebalance the natural gut flora8,9. Conclusion PPI therapy may be useful in some patients. However, risks versus benefits of both short term and long term therapy should be evaluated for each patient. If a patient/provider wishes to stop the PPI, a taper is recommended to alleviate any rebound stomach upset. References: 1. Sheen E, Triadafilopoulos, G. Adverse effects of long-term proton pump inhibitor therapy. Dig Dis Sci 2011;56:931-50. 2. PL Detail-Document, Overuse of Acid Suppressing Drugs in the Hospital. Pharmacist’s Letter/Prescriber’s Letter. July 2009. 3. Vakil N. Acid inhibition and infections outside the gastrointestinal tract. Am J Gastroenterol 2009;104(Suppl 2):S17-20. 4. Gomm W, Holt K, Thome F, et al. Association of proton pump inhibitors with risk of dementia: A pharmacoepidemiological claims data

analysis. JAMA Intern Med 2016;73(4):410-16. 5. Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med 2016;176: 238-46. 6. Reimer C. Safety of long-term PPI therapy. Best Pract Res Clin Gastroenterol. 2013; 27(3): 443-454. 7. Haastrup P., et al. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract 2014; 31(6): 625-630. 8. Murphy S., Grobel H. Weaning GERD Patients off PPIs. Sonoma Medicine 2014;65(1)7-9. 9. Schrezenemeir J., DeVrese M. Prebiotics, probiotics, and synbiotics. Am J Clin Nutr 2001;73:361S-364S.

Proton Pump Inhibitors (PPIs): To Use or Not to Use? Bennett Doughty, Pharm.D., Amber Rollins, Pharm.D., Alyssa Taqi, Pharm.D. PGY-1 Pharmacy Practice Residents, VA Connecticut Healthcare System

3 | Spring 2017 CT-ASCP Chapter Newsletter

The University of Connecticut School of Pharmacy, Office of Pharmacy Professional Development and

the CT Chapter of the American Society of Consultant Pharmacists present:

The 4th Annual Schwarting Senior Symposium

A multi-disciplinary conference focused on senior care and certificate programs for pharmacists and APRN’s as well as other healthcare providers

Thursday, April 6th 2017

6:30am – 7:00pm Aqua Turf Club

556 Mulberry St. Plantsville, CT

4 TRACKS AVAILABLE: Senior Symposium – Track #1

Arthur E. Schwarting Pharmacy Practice Symposium MTM for Patients with Respiratory Disease – Track #2

MTM for Adult Patients with Diabetes – Track #3 Immunization Training for Pharmacists – Track #4

Register today!

http://pharmacy.uconn.edu/academics/ce/schwarting/

4 | Spring 2017 CT-ASCP Chapter Newsletter

Thank you to everyone who attended our first exclusive Members-Only Networking Event

at Wood N Tap!

5 | Spring 2017 CT-ASCP Chapter Newsletter

REVIEW OF PAST MINUTES The 12/05/2016 meeting minutes were reviewed and approved (KR/RE). CHAPTER NEWS Legislative Issues: The National ASCP website has some information regarding

legislative updates! Awards/Scholarship Committee: The immediate past president is typically the

chair for the awards/scholarship committee. B. Pelletier will be looking for volunteers from our board members and our chapter members to assist. Please let B. Pelletier know if you are interested.

Schwarting Senior Symposium: SSS 2017 will be held on Thursday, April 6th at

Aqua Turf Club in Plantsville, CT.

Speakers – the SS Committee has heard back from some of our speakers and has received some learning objectives for their presentations. The committee is still working on finalizing additional speakers. The goal is to have finalized all speakers in

the next few weeks, with the plan to open registration in early-mid February. C.

Pornprasert has been in contact with the director of pain and palliative care from Johns Hopkins who may be a potential speaker. Additionally, the committee may potentially have Tracy

Shamas (palliative care provider from the VA) work with him to do breakout session.

Schedule – A rough draft schedule for SSS 2017 was discussed and the committee working to finalize this. B. Pelletier brought up the idea of doing a two-hour workshop/breakout session on a

designated topic rather than finding two speakers (one for pharmacists and one for APRNs). Given large anticipated attendance at SSS2017 and timing, this idea may be considered in

the fall. Volunteers – A. Sampieri is working to solicit volunteers for various

responsibilities – We will need people in the morning for registration, will have students for introductions of the speakers,

traffic directors, etc. Please let A. Sampieri know if you are interested in volunteering. Sponsors – There will be a passport for visiting sponsor booths, which

will be adapted from last years version. D.Cooper has contacted several sponsors from last year and has heard back from some, with four sponsors finalized. If anyone has leads for potential sponsors, please send to D. Cooper. From attendees of past years of SSS: 37% were hospital pharmacy attendees, 29% were

consulting pharmacy attendees, 21% were retail pharmacy attendees, and 13% other. Product Theaters – J. Nault has heard from Acadia, Sanovian, and Allergan for sponsoring meals at SSS 2017. J. Nault will work on

reserving the Millhouse venue for the dinner the night prior to SSS 2017. She is in the process of finalizing which sponsor will do which meals and the plan is to have this set by early February.

Save the Dates – J. Nault has finalized pricing information on save the date cards, which will be sent to APRNs. The plan is to wait to send these cards until credit information is finalized so that

verbiage confirming credits will be on post card. The goal is to send these out in early February. Additionally, there will be some post cards made without postage for pharmacists to dispense to APRN colleagues. The plan is to send electronic save the date to pharmacist e-mail list at the end of the week/early next week.

Several e-mails will be sent prior to event to solicit potential pharmacist attendees.

Guests: Christina Pornprasert, Mark Wrabel, Joanne Nault, Macayla Landi, Catherine Liu, Erica Estus, David Cooper, 2 USJ students Meeting adjourned at 7:20 pm (KD/MS). Next Meeting: 2/13/17 (USJ – Hartford – need to finalize panel participants for this meeting and discuss timing/meal arrangements) Respectfully submitted, Melissa Striglio, PharmD, BCPS CT-ASCP Board of Directors

Notes 'n Votes - January 2017 Board Meeting Melissa Striglio, PharmD, BCPS, CT-ASCP Secretary / Treasurer

Editorial Board ¾Anna Torda, PharmD, CACP ¾Kim Daley, PharmD, CDP ¾Kevin Chamberlin, PharmD ¾Brian Pelletier, PharmD, CGP ¾Jennifer Kloze, PharmD, BCPS

MEMBER NAME & TITLE Nov Dec Jan

Brian Pelletier President / Legislative Committee

X X X

Mike Gemma Immediate Past President

X

Karen Rubinfeld President-elect

X X X

Melissa Striglio Secretary / Treasurer

X X X

Anna Torda, Board 2016-2019 / Comm. Committee

X X

Dolores Ciccone Board 2016-2018

X X

Andrea Leschak Board 2015-2018 / SSS Committee

X X X

Anna Sampieri Board 2015-2018

X X

Kim Daley Board 2015-2017 / Comm. Committee

X X

Rachel Eyler Board 2014-2017

X X