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PPI – Appropriate Prescribing

This Project takes 2-3 months for a practice with 10,000 patients

Can be done by a GP, Pharmacist, Trainee or Student

Green Impact for Health Toolkit area: Prescribing & Quality Improvement

CQC Areas

  • Safe (Medicines Optimisation)
  • Effective (Delivering Evidenced Based Care)
  • Effective (Supporting People to Live Healthier Lives)
  • Well-led (Learning, Improvement & Innovation)
  • Well-led (Environmental Sustainability)

On this page

The benefits of this project

Project benefits for Your Patients

Benefits for Your Patients

  • Reduced risk of side effects
  • Reduced reliance on medication
  • Improved self-care
Project benefits for Your Practice

Benefits for Your Practice

  • £1144/year per 100 patients having long-term PPI stopped (medicines spend savings - based on omeprazole 20mg capsule price Feb 2025)
  • Reduced prescribing leading to lower side effects, appointment demand & administration for prescriptions
Project benefits for The Planet

Benefits for The Planet

  • Reduced medicines carbon emissions
  • Reduced medicines waste pollution

Opportunity for improvement

  • Proton Pump Inhibitors (PPIs) are one of the most prescribed medications in General Practice and are used by ~15% of the UK population. They are an effective and safe treatment for conditions such as acid reflux and gastric ulceration as well as offering gastric protection from other medications e.g. NSAIDs.  
  • There are a few conditions that require long term treatment with a PPI. However, many patients are started on a course of PPI therapy and then not reviewed or encouraged to reduce and stop it.  
  • PPIs can cause side effects esp. with longer-term use including increased risk of Clostridium difficile infection, increased risk of fractures and osteoporosis. They can lead to reduced absorption of B12 and iron plus hypomagnesaemia and hyponatraemia. They can mask the symptoms of gastric cancer and may also increase the risk of some cancers.   
  • Appropriate prescribing is beneficial, not only to patient health, but also the environment as it reduces unnecessary side effects, costs, and waste. For many patients, lifestyle modifications, for example weight loss and avoiding triggers such as smoking, spicy food & alcohol, can improve reflux symptoms without the need for medication.  
  • In 2022-2023 ~£190 million was spent on PPI prescriptions in England, equating to 1.8% of total primary care prescription costs. 
  • This project outlines how to reduce inappropriate prescribing of long-term PPIs in practice (see disclaimers) and helps address the NHSE medicines optimisation opportunity ‘addressing problematic polypharmacy’. 
  • You might like to create a SMART goal for this project e.g. to reduce the number of patients with a PPI on repeat prescription without a clear indication by 50% over 3 months.   

How to carry out this project

  1. Identify patients

    Run a search for all patients with PPI medications on their repeat prescriptions and exclude those:  

    • coded as having ‘Barrett’s Oesophagus, Zollinger Ellison, oesophageal stricture, severe oesophagitis, previous gastrointestinal bleed’. 
    • any patients aged over 70 years old and on aspirin. 
    • any patients on dual antiplatelet therapy or long term NSAID medications.

     This should give you a list of patients for whom long-term PPI medication is unlikely to be recommended.  

    We hope to provide downloadable IT searches for EMIS & System 1 soon.  In the meantime, you could use our EMIS and SystmOne search guides to create your own. 

  2. Training for Clinicians

    An education session should be held for clinicians to:  

    • raise awareness of the importance of lifestyle advice for managing reflux.  
    • raise awareness of PPI prescribing guidance for reflux i.e. PPI for 4-8 weeks and then wean down and stop if symptoms resolved.2,6,7 This algorithm may be helpful.8 
    • advise prescribing PPIs as acute issues and adding an end date if a repeat prescription is issued plus a stop date to be added to dosage directions (unless long-treatment needed).   

  3. Patient Information

    Provide prescribers with a text message which can be sent to patients when they are prescribed PPIs for reflux: 

    Resource: PPI SMS

    Simple lifestyle changes can often treat acid reflux. You might find it helpful to eat smaller meals, avoid eating 3-4hr before bed, avoid things which trigger acid such as smoking, alcohol, coffee, spicy or fatty foods and try to lose weight if you are overweight. We have prescribed a proton pump inhibitor medication to help your symptoms. Try it for 4-8 weeks and then stop if you feel better. It can be used when needed but aim for the shortest time possible as long-term regular use is associated with increased risk of side effects (although is needed for some patients). Let us know if you don’t feel better whilst taking it. https://www.nhs.uk/conditions/heartburn-and-acid-reflux/

  4. Plan

    Discuss the next steps with your practice GP prescribing lead, pharmacist, and wider practice team. What you decide to do will depend on the number of patients found in step 1, what system the practice uses for prescribing and medications reviews and the practice capacity for medication review appointments.   

    If the list of patients found in step 1 is too large, use a random number generator to get a manageable cohort of patients or prioritise certain patients e.g. those on highest dose.   

    You might add choose a code to be added when a PPI discussion happens so that those patients can be excluded from future searches.  

  5. Do

    Here are some different approaches you might then take.   

    1. Contact all patients identified for a medication review and discuss lifestyle advice and reducing and stopping their PPI.
    2. Add an alert to the notes of all patients identified to highlight that a discussion about PPIs is needed at their next medication review.
    3. Review the notes of all patients identified and if nil indication for long-term PPI, stop their PPI and send them a text message: 

    Resource: Stopping PPI SMS

    Long-term use of proton pump inhibitors (PPIs) such as omeprazole is associated with increased risk of adverse effects such as bone thinning, fractures and increased risk of infection and mineral deficiencies. Simple lifestyle changes can often treat acid reflux. https://www.nhs.uk/conditions/heartburn-and-acid-reflux/ We are therefore stopping repeat PPI prescriptions for our patients who do not have specific indications for long-term use. Please book in for a medication review if you feel you still need this medication.

  6. Record how many patients had their PPI stopped.

  7. Communicate with local pharmacists

    Involve your local community pharmacists so they are aware of the recommendations and can support with consistent messaging to patients.  Your practice pharmacist will likely know how best to get in touch with them.   

  8. Study

    Review the results, summarise learning, share with practice team + decide if any changes are needed to improve the process. Decide when to re-audit again to ensure the change has lasted e.g. 2-3 months and use the Project Monitoring form to keep track. Many practices run automatic searches at regular intervals – speak to your practice team about including this project in those searches. 

Top tip

Involve all the clinicians so that, even if not as part of a medication review, they might mention reducing PPI medication to patients when they see them for other issues.

How to scale this project up or down

Please note - Use of this project requires NetworkPLUS membership. If you would like to share this project with others, please invite them to purchase their own membership—access must not be shared with non-members.

You could upscale this project by taking it to your Primary Care Network (England), Cluster (Scotland & Wales) or SPPG pharmacist (Northern Ireland) to implement across all practices in your area.   

Have you completed this QIP?

Tell us a little about your project and enter your data in order to generate a certificate showing the probable cost and carbon savings and other benefits. This project may help with CQC evidence submission (see disclaimers). 

Get your certificate

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