Overutilization of proton-pump inhibitors: what the clinician needs to know

Abstract

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffinlike cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

The effect of dose and type of proton pump inhibitor use on risk of fractures and osteoporosis treatment in older Australian women: A prospective cohort study

“…Although many confounders were included, residual confounding may exist. Other studies have suggested some potential confounding variables that were not measured in the current study, including vitamin B12 deficiency, community acquired pneumonia, clostridium difficile, Helicobacter pylori [3,41] and celiac disease [42]. The large population based case-control study by Lam et al [41] on PPI use and vitamin B12 deficiency, showed a significant association between previous and current PPI use and the existence of a vitamin B12 deficiency.…”

“…These findings highlight the need for a more careful approach to PPI prescription, as treating resulting osteoporosis may not be easy. As PPI treatment is often continued without verification or repeated confirmation of indication and/or lowest dose prescription, treatment on demand and step-down therapy should be considered more often [3,49].…”

“…Consequently, proton pump inhibitors (PPIs) to treat these disorders are among the most widely prescribed medications worldwide [1,2]. PPIs are indicated for several acid-related upper gastrointestinal disorders, including gastro-oesophageal disease (GERD), dyspepsia, peptic ulcer disease and as prophylaxis for non-steroidal anti-inflammatory drugs-associated upper gastrointestinal complications [3]. Due to their effectiveness and perceived short-and long-term safety, PPIs account for 95% of acid suppressing medication prescriptions [1].…”

“…More recently, a growing concern is the safety of PPIs; several adverse effects of long term PPI use have been reported, including decreased bone quality [3,7]. Warnings about PPIs and potentially increased fracture risk have been issued in Australia and in the US [8,9].…”

A Pharmacist-Led Medication Use Evaluation of Proton-Pump Inhibitors

“…Because of the risk factors associated with the prolong use of PPIs, it is important that patients follow-up with their physicians for reevaluation. Studies have revealed that overutilization of PPIs happens quite frequently and occurs primarily in patients requiring long-term treatment [7].…”