Patient mailings reduce long-term proton pump inhibitor use
Mailing education to patients plus guidance to clinicians roughly doubled meaningful dose reduction of long-term proton pump inhibitor use without worsening reflux symptoms.
*Pragmatic cluster randomized clinical trial; Level 1b (OCEBM).

Citation

Fournier J-P, Gaultier A, Riche V-P, Tessier P, Rat C, Nguyen-Soenen J. Deprescribing intervention and reduction of proton pump inhibitor use in primary care: a cluster randomized clinical trial. JAMA Internal Medicine. 2026;186(6):668-676. doi:10.1001/jamainternmed.2026.0584

Background

Long-term proton pump inhibitor use is often unnecessary and may cause harm and higher costs. This study tested a health system–scale approach to encourage safe reduction in primary care.

Patients

Adults (≥18 years) in western France with at least 1 year of high proton pump inhibitor use (>300 defined daily doses in the prior year). Excluded: patients at higher ulcer-bleeding risk (older than 65 years using anti-inflammatory pain medicines) and those using steroids, blood thinners, or antiplatelet medicines.

Intervention

Mailing to patients: educational brochure plus motivational letter; mailing to clinicians: deprescribing letter plus step-by-step dose-reduction algorithm.

Control

Clinician-only mailing (letter + algorithm) or usual care.

Outcome

Primary: ≥50% reduction in annual proton pump inhibitor use (from reimbursement claims). Secondary: reflux symptom scores in a 10% sample using a 1-to-4 scale (1=never, 4=daily); a change ≥0.5 is clinically meaningful.

Follow-up Period

1 year

Results

Comparison Patients with ≥50% annual dose reduction Adjusted absolute difference NNT
Patient+clinician mailings vs usual care 14.9% vs 7.0% +6.9% 15
Patient+clinician mailings vs clinician-only mailing 14.9% vs 7.7% +6.7% 15
Reflux symptom scores did not differ between groups and changes were not clinically meaningful. Analysis used a modified intention-to-treat approach.

Limitations

Medication use was inferred from reimbursements, not confirmed swallowing of pills. Reflux symptoms were measured only in a small sample with incomplete responses and only at 1 year, which may miss short-term rebound symptoms. Claims data could not fully rule out appropriate long-term use (such as severe esophagus disease).

Funding

French Ministry of Health grant (PREPS-19-0040); no funder role.

Clinical Application

For long-term users without high bleeding risk, consider mailing patient education plus clinician guidance; expect modest but meaningful reductions without worsening reflux symptoms.