Medicine sustainability interventions
Clinical care and outpatient care
Discontinuation of proton pump inhibitors without a current indication
Proton pump inhibitors (PPIs) are antacids that are frequently used. Pantoprazole (1.3 million users) and (es) omeprazole (1.2 million users) were among the top 3 most used medicines in 2023 (1). However, it appears that a large number of these drug users have no indication for PPI use (2). In short-term use, more than half of the patients appeared to have no indication (3); in chronic use, this figure is even 87% (4). Overtreatment with PPIs risks side effects, such as an increased risk of bone fractures and vitamin B12 deficiency, but also leads to unnecessary costs and environmental impact (2).
The NHG 'Stomach Disease (NL)' guideline and the NVMDL guideline 'Gastroesophageal Reflux Disease (NL)' provide recommendations to prevent overtreatment with PPIs (5.6). These guidelines recommend that patients with stomach problems or disorders with a temporary indication for PPIs should reduce a PPI within three months. Only patients with grade C and D4 reflux esophagitis, Barrett's oesophagus and Zollinger-Ellison syndrome should use a PPI for life (5 - 7). A PPI for stomach protection should be stopped when a patient stops taking the medication for which it was prescribed (8).
The Proton Pump Inhibitors Knowledge Paper (NL) explains the consideration for reducing or discontinuing proton pump inhibitors when using PPIs chronically (7). Reducing appears to be successful in approximately 40 - 70% of the patients, depending on the intervention that is chosen (9). In this way, any long-term side effects of PPIs can be prevented and costs and environmental impact can be saved (5 - 7).
Intervention
Identifying, phasing out and stopping unnecessarily used proton pump inhibitors (long-term use without indication).
Note: This intervention is specifically about stopping unnecessary PPI use. Targeted starting is covered in the intervention “targeted prescribing of PPIs as stomach protection”.
Environmental impact
Measured in CO2-emissions by reducing the number of prescriptions and/or the dosage of (es) omeprazole and pantoprazole.
Working method
1. Determine the population and formulate a goal
- Inventory current policies in selected department/for selected patient group (s):
- Pre-measurement of the number of PPIs prescriptions based on (outpatient) clinical prescribing and/or administration data according to “Method of evaluating a drug intervention”.
- If necessary, determine what proportion of prescriptions meets the indication criteria.
- Formulate SMART goals together with (the green team of) the relevant department (s). For example: within three months, a 10% reduction in PPI prescriptions in patients who visit the MDL outpatient clinic without a current indication for PPI use.
- Research shows that at least 40-80% of patients who use PPI for a long time and discontinue or discontinue it are possible (7).
- PPI reduction has been studied for patients in the outpatient clinics of MDL, internal medicine, rheumatology and kidney disease (9).
2. Implementation
This intervention can be performed in several ways depending on the hospital's preference (Table 1). For all working methods, you can start with training.
Outpatient: during consultation
- Generate topic attention, for example through a PPI stop month, where you regularly remind colleagues in the transfer to stop unnecessarily used PPIs.
- Check the indication of PPI during medication control in regular consultations.
- Support: give patient (digital) flyer*1 and/or access to the Patient Journey App*2 with more information about phasing out/discontinuing PPIs.
- Follow-up: If you have any questions or complaints, the patient can contact the attending physician. When using the app, guidance is automatically provided based on questionnaires and reminders.
Outpatient: department-wide via screening
- Screening: pharmacist/ICT makes an EHR list of patients who use a PPI for >3-6 months.
- Selection: local project coordinator for patients with no clear indication for PPI use and communicates with treating specialists.
- Assessment: treating specialist determines whether PPI is still necessary.
- If there is no indication, the patient will be approached by project coordinator or treating doctor for discontinuation or phasing advice.
- Support: patient receives a digital folder and/or access to the Patient Journey App (proven effective, guided with reminders and tips).
- Follow-up: If you have questions or complaints, the patient can contact the local project coordinator or treating doctor. When using the app, guidance is automatically provided based on questionnaires and reminders.
Clinical: during medication reviews
- Upon admission: during medication verification by a pharmacist's assistant:
- If there is a PPI on the home medication overview, the indication will be requested.
- During stay: evaluate PPI use during scheduled medication reviews
- In case of dismissal: state stop PPI in the dismissal recipe and letter of resignation.
Table 1: comparison of PPI reduction interventions
For all three working methods, it is important that there is a good transfer to primary care, see “Ensuring information transfer between hospital and primary care”.
3. Monitoring and Evaluation
- Provide feedback, for example with the help of (outpatient) clinical prescriptions or completed questionnaires, depending on the implementation method chosen. Discuss (interim) results regularly, for example (twice) monthly in a team meeting or transfer. For example, how many patients are willing to reduce and reduce (outpatient) clinical PPI prescriptions.
- Reflect on results in relation to the set goal, obstructing and promoting factors. Adjust interventions if necessary.
- At the end of the follow-up period, evaluate whether the goal (s) is/have been achieved and how the change is secured.
How is this measured?
Depending on the method chosen, the environmental impact can be determined by the number of (outpatient) clinical prescriptions and/or administrations (es) of omeprazole or pantoprazole per three months, see “Method of evaluating a drug intervention”.
If the Patient Journey App has been used, the completed questionnaires can be used to determine what proportion of patients have successfully stopped.
Note: The intervention 'targeted prescribing of PPIs as stomach protection may influence the outcomes of this intervention.
When successfully implemented?
Based on the reduction in the number and dosage of PPI prescriptions and/or administrations, as described in the previous section, determine when the implementation is considered successful, and reflect on the set goal.
Footnotes
*1 The Patient Journey App assists the patient in reducing PPIs (3). In addition to background information about indications for use and possible side effects, it mainly provides information about how to reduce PPIs safely and successfully (through a phasing out schedule), the risk of rebound symptoms and how to prevent or treat them. Through regular contact moments with information and questions about how things are going, the app offers interactive guidance based on patient complaints and questions for 2 months. A recent study by Radboudumc showed that 86% of patients were able to stop PPIs successfully using the app, compared to 64% of patients who received a regular flyer. The app requires a license, the cost of which is approximately €9,000 per year excluding VAT and one-off start-up costs of €3,000 — 4,000. In many hospitals, this app is already being used for other care paths, which makes implementation easier. Do you want to know if this app is already being used in your hospital, or would you like more information about this? Then contact us via the website www.patientjourneyapp.nl.
Resources
- Foundation for Pharmaceutical Key Figures (SFK). Data and facts 2024: Drug use in the Netherlands. The Hague: SFK; 2024. Accessed on: July 29, 2025. Available at: https://www.sfk.nl/publicaties/data-en-feiten/data-en-feiten-2024
- Health care institute. Improve the sign of an upset stomach. Diemen: Health Institute,; 2021. Contract No.: ICD-10: XI K21- K3.
- Koggel LM, Lantinga MA, Büchner FL, et al. Predictors for inappropriate proton pump inhibitor use: observational study in primary care. Br J Gen Pract. 2022 Nov 24; 72 (725) :e899-e906. doi: 10.3399/BJGP.2022.0178.
- Müskens JL, van Dulmen SA, Wiersma T, et al. Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study. Br J Gen Pract. 2022 Apr 28; 72 (718) :e369-e377. doi: 10.3399/BJGP.2021.0625.
- NHG standard Stomach problems [Internet]. Utrecht: Dutch General Practice Association; 2021 [updated Apr 2025]. M36. Available via: https://richtlijnen.nhg.org/standaarden/maagklachten#volledige-tekst
- Federation of Medical Specialists. Gastroesophageal Reflux Disease Directive. Accessed on: July 29, 2025. Available at: https://richtlijnendatabase.nl/richtlijn/gastro-oesofageale_refluxziekte
- SIR Institute for Pharmacy Practice and Policy. Multidisciplinary Guideline “Polypharmacy in the elderly” - Module “Reducing and stopping medication”, Proton Pump Inhibitors Knowledge Document. Available via: https://richtlijnen.nhg.org/multidisciplinaire-richtlijnen/polyfarmacie-bij-ouderen. Accessed on August 11, 2025.
- De Jongh E, De Wit NJ, Numans ME, et al. NHG treatment guideline: Prevention of stomach complications due to drug use [Internet]. Utrecht: Dutch General Practice Association; March 2021. Accessed on: July 29, 2025. Available at: https://richtlijnen.nhg.org/behandelrichtlijnen/preventie-van-maagcomplicaties-door-geneesmiddelgebruik
- Ball LM, Timmers T, Lantinga MA, et al. Efficacy of an App-Based Proton Pump Inhibitor Discontinuation Tool: An Open Randomized Superiority Trial. Available at SSRN: https://ssrn.com/abstract=5287453 or http://dx.doi.org/10.2139/ssrn.5287453
- Improve the sign of an upset stomach. Sensible Care. Zorginstituut Nederland (2021). ICD-10: XI K21- K30. Sensible Care - Stomach complaints improvement sign | Report | Zorginstituut Nederland.
- Polypharmacy guideline for elderly people - Module: reducing and stopping medication (2020). Accessed on July 28, 2025. Available at: https://richtlijnendatabase.nl/richtlijn/polyfarmacie_bij_ouderen/minderen_en_stoppen_van_medicatie.html.
Tools
Are any materials missing here or have you (developed) additional materials that can help other hospitals implement this intervention, please let us know via contact@samendezorgvergroenen.nl
- Environmental Impact Proton Pump Inhibitors Toolkit: Follows
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Clinical care and outpatient care
Targeted prescribing of proton pump inhibitors (as stomach protection)
Proton pump inhibitors (PPIs) are antacids that are frequently used. Pantoprazole (1.3 million users) and (es) omeprazole (1.2 million users) were among the top 3 most used medicines in 2023 (1). However, it appears that a large number of these drug users have no indication for PPI use (anymore) (2). With short-term use, more than half of the patients appeared to have no indication (3). Part of this is caused by starting PPIs as stomach protection without indication.
The NHG guideline “Prevention of stomach complications due to drug use (NL)” and the knowledge document proton pump inhibitors (NL) indicate that a PPI is indicated as stomach protection based on risk factors, such as age, ulcer or history of stomach complications, NSAID dosing, co-medication with an increased risk of stomach complications and comorbidities, such as rheumatoid arthritis, heart failure or diabetes (4 - 6). By prescribing PPIs based on risk factors for stomach protection, unnecessary PPI use can be reduced, thereby preventing environmental impact.
