Table 10.
Consensus statements agreed upon by the experts using the Delphi method
| Best practice consensus statements | Level of agreement* | Strength of expert opinion |
|---|---|---|
| Appropriate use of acid suppressants | ||
| Patients with GERD and acid-related complications (i.e., EE or peptic stricture) should receive PPI therapy for 8–12 weeks for the healing of esophagitis. The duration of therapy for symptom control should be adjusted on a case-to-case basis | 100% | Conditional |
| Strongly agree: 92% | ||
| Agree: 08% | ||
| Acid suppressants, particularly PPIs, should not be routinely co-prescribed for prophylaxis with commonly used drugs like antibiotics/iron preparations/calcium antagonists/corticosteroids/NSAIDs, etc., which are likely to cause GI disturbances | 100% | Strong |
| Strongly agree: 73% | ||
| Agree: 27% | ||
| PPIs should not be prescribed as 1st line treatment option in patients who have non-specific abdominal pain/for on-demand use when safer alternatives like H2RAs (e.g., ranitidine, famotidine) and antacids are available | 100% | Strong |
| Strongly agree: 91% | ||
| Agree: 09% | ||
| PPIs need not be prescribed in acute cases of nausea and vomiting in cases unrelated to GERD, esophagitis/PUD | 100% | Conditional |
| Strongly agree: 83% | ||
| Agree: 17% | ||
| PPIs need not be prescribed routinely in all patients taking drugs like aspirin/clopidogrel/NSAIDs/steroids/oral anticoagulants as a monotherapy, who are at low risk for GI bleeding | 100% | Conditional |
| Strongly agree: 50% | ||
| Agree: 50% | ||
| PPIs need to be routinely prescribed 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 | 100% | Conditional |
| Strongly agree: 42% | ||
| Agree: 58% | ||
| Routine prescription of PPIs in anemia patients without evidence of GI bleeding should be discouraged | 100% | Strong |
| Strongly agree: 92% | ||
| Agree: 08% | ||
| In patients on PPI therapy with persistent night-time symptoms, bedtime H2RAs like ranitidine or famotidine should be considered | 100% | Strong |
| Strongly agree: 67% | ||
| Agree: 33% | ||
| PPIs should not be used as 1st line treatment option in special populations like pregnant women experiencing heartburn and pediatric patients less than one year of age, especially when safer alternatives like H2RAs (e.g., ranitidine, famotidine) are available | 100% | Strong |
| Strongly agree: 75% | ||
| Agree: 25% | ||
| PPIs should be prescribed cautiously in patients diagnosed with conditions like IBD, microscopic colitis, spontaneous bacterial peritonitis, and fundic gland polyps | 100% | Strong |
| Strongly agree: 42% | ||
| Agree: 58% | ||
| Safety and monitoring of AST | ||
| The risk of dysbiosis, GI, and non-GI infections is higher with PPIs as compared with H2RAs in children and adults | 92% | Strong |
| Strongly agree: 33% | ||
| Agree: 58% | ||
| Neither agree or disagree: 08% | ||
| Daily long-term treatment with AST, especially PPIs, can be associated with an increased risk of vitamin (B12 and D) and mineral deficiencies (calcium, iron, and magnesium), and patients at high risk need to be monitored for nutritional deficiencies | 92% | Strong |
| Strongly agree: 42% | ||
| Agree: 50% | ||
| Neither agree or disagree: 08% | ||
| Long-term PPI use may be associated with an increased risk of adverse cardio-renal outcomes, including AKI | 100% | Strong |
| Strongly agree: 50% | ||
| Agree: 50% | ||
| Concomitant use of NSAIDs with PPIs may increase the risk of AKI | 100% | Strong |
| Strongly agree: 33% | ||
| Agree: 67% | ||
| Prolonged PPI use may be associated with an increased risk of fractures as compared with H2RAs | 100% | Strong |
| Strongly agree: 64% | ||
| Agree: 36% | ||
| Long-term PPI use (>12 weeks) in all patients with liver cirrhosis, CKD, and CVD should be avoided unless strongly indicated | 100% | Strong |
| Strongly agree: 58% | ||
| Agree: 42% | ||
| It is appropriate to monitor 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 | 91% | Weak |
| Strongly agree: 27% | ||
| Agree: 64% | ||
| Neither agree or disagree: 09% | ||
| Deprescribing PPIs | ||
| All patients taking PPI should undergo a regular review of the ongoing indications for use. In patients without a definitive indication, PPI should be stopped/de-prescribed | 100% | Strong |
| Strongly agree: 58% | ||
| Agree: 42% | ||
| Most patients with an indication for long-term PPI use who are currently on twice-daily dose can be considered for step down to once-daily PPI | 100% | Strong |
| Strongly agree: 50% | ||
| Agree: 50% | ||
| 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 | 100% | Strong |
| Strongly agree: 80% | ||
| Agree: 20% | ||
| Patients discontinuing long-term PPI therapy should be advised about transient upper GI symptoms due to rebound hyperacid secretion | 100% | Strong |
| Strongly agree: 83% | ||
| Agree: 17% |
*Level of the agreement includes strongly agree and agree votes; AST, acid suppressant therapy