Concordance between use of proton pump inhibitors and prescribing guidelines

Abstract

Objective To determine (i) the relationship between prescriptions for proton pump inhibitors (PPIs) and upper gastrointestinal conditions, and (ii) compliance with Pharmaceutical Benefits Scheme (PBS) prescribing guidelines for PPIs. Design Drug utilisation evaluation. Setting 800‐bed metropolitan teaching hospital. Participants 253 patients dispensed PPIs from the hospital pharmacy over five consecutive weeks (11 January to 15 February 1999). Main outcome measures Recorded gastrointestinal conditions; previous trial of H2‐ antagonist therapy; compliance with PBS criteria for prescribing PPIs. Results Seventy patients (27.7%) had no appropriate upper gastrointestinal tract investigations, and 62 patients (24%) did not receive an adequate trial of H2‐antagonist therapy before the commencement of a PPI. The major indications for use of PPIs in investigated patients were gastro‐oesophageal reflux in 99 (54%) and peptic ulcer disease in 30 (16.4%). In only 57 patients (22.5%) did PPI prescriptions comply with PBS prescribing guidelines. Clinical indications that failed to meet prescribing criteria included milder forms of gastro‐oesophageal reflux, gastritis/duodenitis, and non‐specific dyspepsia with normal endoscopy results. Conclusion Drug utilisation data indicate widespread use of PPIs outside current prescribing guidelines. Many patients have not had relevant investigations and/or an adequate trial of H2‐antagonist therapy. These findings explain the considerable hospital expenditure on PPIs.

Overuse of proton pump inhibitors

“…In total, 72% of patients were considered to have undergone appropriate investigation before commencing a proton pump inhibitor. A recent study in Brisbane also found that 72% of patients were investigated appropriately before a proton pump inhibitor was commenced (30).…”

Proton pump inhibitors: a survey of prescribing in an Irish general hospital

“…Two-thirds of the patients prescribed PPI therapy in our study had not undergone upper GI endoscopy. Newton et al (8) found that one quarter of their patients had been prescribed PPI therapy with no prior investigation compared with 28% in the study by Pillans et al (7). Naunton et al (9) found that endoscopy had been performed in only 54% of patients prior to commencing PPI therapy.…”

“…The standard prescribed daily dose of omeprazole is 20 mg, but over 30% of our patients on omeprazole were prescribed 40 mg daily. In their survey of hospital prescribing, Pillans et al (7) found that the prescribed daily dose of omeprazole was more than 20 mg in 39% of patients.…”

“…Just over 70% of PPI prescriptions in our study originated in hospital but one-fifth had been initiated in primary care prior to hospital admission. Newton et al (8) found that 77% of PPI prescriptions were initiated in hospital compared with 66% in the Australian study by Pillans et al (7). Given the diagnostic facilities and expertise available in the hospital setting, it might be anticipated that most patients prescribed PPI therapy would have undergone appropriate investigations.…”

Inappropriate prescribing of proton pump inhibitors in primary care

“…Current evidence suggests PPIs are often overused. [3][4][5][6][7][8] PPIs are not without their side effects (diarrhoea, headache in up to 10%), and studies have linked the use of PPIs to an increased risk of community acquired pneumonia, 9 10 C difficile diarrhoea, [11][12][13] and Campylobacter jejuni gastroenteritis. 14 PPIs also have interactions with many drugs 15 and can occasionally cause severe adverse reactions such as hepatic, renal, skin, and bone marrow toxicity and anaphylaxis.…”