Rationalizing the use of PPIs: An unresolved matter

Abstract

The abnormally high use of proton-pump inhibitors (PPIs) has been repeatedly denounced for many years (1), and attention has been drawn towards the economic burden it represents (2,3). Multiple scientific publications have reported this problem in many countries. In the present issue of the Journal an observational, prospective study based on a survey to analyze the inappropriate (not recommended by clinical guidelines) indication of chronic PPI use (daily for over one year) in outpatients seen at a specialty hospital in Mexico is reported (4). The authors find an overall rate of inappropriateness of 35.3 %, a figure within the lower range of those reported, which exceed 60 % in many countries including Australia (5,6), United Kingdom (7), and Greece (8), and in four studies performed in Spain (9,10-12). All these studies discuss oral therapy with PPIs, but inappropriateness is also very high (above 75 %) in terms of dosage and length of intravenous therapy (13).The introduction of antisecretory agents in clinical practice, initially H 2 antagonists and then PPIs, has brought in the treatment of conditions associated with gastric acid secretion. The indisputable greater effectiveness of PPIs makes them preferable progress to H 2 antagonists . In a study that examined the indication of antisecretory agents at hospital admission and discharge for gastro-esophageal reflux disease (GERD) and peptic ulcer, two conditions where prescription is appropriate, PPIs were chosen in over 95 % of cases (14).PPI prescription is quantitatively high because of factors inherent to these drugs (high therapeutic efficacy and safety) and the high prevalence of diseases where they are appropriately indicated. GERD -the paradigm here-accounts for almost all appropriate PPI prescriptions for chronic use, and is followed by the prophylaxis of gastric disease by non-steroidal anti-inflammatory drugs (NSAIDs). Sánchez Cuén et al. (4) note that GERD is the most common appropriate indication (31,3 %), representing over 70 % of all appropriate indications.Disease-related factors that account for a high use of PPIs include the high prevalence and chronic nature of GERD, as well as the frequent need for prophylaxis of NSAID-related gastropathy, which is presumably increasing (population ageing associated with comorbidity and a higher number of therapies representing risk factors, including anticoagulants, antiaggregants, etc.). These factors justify a high number of prescriptions for continous PPI therapy, as reported by health agencies. According to the latest official data, PPI use in Spain increased by 227 % during the 2004-2010 period; however, the cost for the Treasury only increased by 21.3 %, from €516 to €626 million, which is increased, nevertheless, a significant sum of money. It is of note that the increased expense principally in the first two years and has remained virtually identical (€626 million in 2006) during the last five years of the mentioned above period. Thus, costs per prescription have decreased, most likely

Inappropriate use of proton pump inhibitors, guidelines and clinical research

“…We have read with interest the paper by Sanchez-Cuén JA et al (1) on inadequate indications in the chronic use of proton pump inhibitors (PPIs), as well as the editorial on rationalizing the use of PPIs by Ponce and Esplugues (2).…”

Reasons for initiation of proton pump inhibitor therapy for hospitalised patients and its impact on outpatient prescription in primary care

“…Currently, gastroesophageal reflux disease accounts for most of the approved indications for PPIs for long-term use, followed by prophylaxis against nonsteroidal anti-inflammatory drugs (NSAIDs) (1). The high prevalence of gastroesophageal reflux disease, its chronic nature and the concomitant presence of other risk factors such as the aging of the population, which is often associated with increased morbidity or treatments that increase the risk of bleeding such as anticoagulants or antiplatelets, contribute to a very high prescription of PPIs (2,3).…”

An economic analysis of inadequate prescription of antiulcer medications for in-hospital patients at a third level institution in Colombia

“…It is necessary that all related works determine economic indicators such as DHD and cost per 100 beds per day that will allow other researchers to make comparisons among different populations and hospitals. Some authors have proposed intervention measures for this problem, with the best results shown by adhesion to clinical practice guidelines and evidence-based protocols (7,37,38).…”

“…Additionally, they have been used for different indications from those recommended, as polymedication, with the exception of gastrolesive drugs, which present clearer indications for their prescription, including criteria such as age and risk factors for upper gastrointestinal hemorrhage, and are not simply used as mucosa protectors (5)(6)(7).…”