Non-guideline-recommended prescribing of proton pump inhibitors in the general population

Proton pump inhibitor use: systematic review of global trends and practices

PURPOSE

Proton pump inhibitors (PPIs) reduce acid secretion in the stomach and rank as one of the most widely used acid-suppressing medicines globally. While PPIs are safe in the short-term, emerging evidence shows risks associated with long-term use. Current evidence on global PPI use is scarce. This systematic review aims to evaluate global PPI use in the general population.

METHODS

Ovid MEDLINE, Embase, and International Pharmaceutical Abstracts were systematically searched from inception to 31 March 2023 to identify observational studies on oral PPI use among individuals aged ≥ 18 years. PPI use was classified by demographics and medication factors (dose, duration, and PPI types). The absolute numbers of PPI users for each subcategory were summed and expressed as a percentage.

RESULTS

The search identified data from 28 million PPI users in 23 countries from 65 articles. This review indicated that nearly one-quarter of adults use a PPI. Of those using PPIs, 63% were less than 65 years. 56% of PPI users were female, and "White" ethnicities accounted for 75% of users. Nearly two-thirds of users were on high doses (≥ defined daily dose (DDD)), 25% of users continued PPIs for > 1 year, and 28% of these continued for > 3 years.

CONCLUSION

Given the widespread use PPIs and increasing concern regarding long-term use, this review provides a catalyst to support more rational use, particularly with unnecessary prolonged continuation. Clinicians should review PPI prescriptions regularly and deprescribe when there is no appropriate ongoing indication or evidence of benefit to reduce health harm and treatment cost.

Assessment of proton-pump inhibitor use at a tertiary teaching hospital in Nigeria

Background:

Proton-pump inhibitor (PPI) is a widely used medication class globally. Because of its good safety profile, there is a huge likelihood of inappropriate use.

Objectives:

To determine the prevalence of PPI use and indications, describe its pattern of usage, and identify factors associated with inappropriate prescriptions at a federal tertiary teaching hospital in Maiduguri, Nigeria.

Methods:

PPI prescriptions were retrospectively assessed in the General Outpatients’ Department (GOPD) and Gastroenterology Unit (GITU) of a teaching hospital. Relevant data for the study were extracted from the patients’ medical records. Chi-square or Fisher’s exact tests where appropriate were used to identify factors associated with inappropriate PPI prescriptions. A p < 0.05 was considered to be significant.

Results:

PPIs were prescribed to 73.3% (220/300) of patients, while inappropriate prescriptions were noted in 91.4% (201/220) of these patients. Epigastric pain (49.5%) was the most common PPI indication, while omeprazole was the highest prescribed (53.4%). Nearly all inpatients (98.2%), those with epigastric pain (95.7%), and patients who were prescribed intravenous PPIs had more inappropriate PPI prescriptions compared to others.

Conclusion:

This study revealed a high prevalence of PPI use and inappropriate prescriptions at the study hospital. As a result, these findings highlight the importance PPI-based stewardship program at the study hospital.

Proton pump inhibitor and community pharmacies: Usage profile and factors associated with long-term use

Aim

To characterize the usage profile and the factors associated with the prolonged use of proton pump inhibitor drugs in a community pharmacy.

Methodology

This is a cross-sectional, prospective and observational study involving interviews with 410 patients who acquired PPI for their own use from community pharmacies. To characterize the factors associated with the prolonged use of PPI, a multivariate logistic regression model was used.

Results

Pantoprazole (42.7%) and omeprazole (31%) were the most acquired PPIs, prescribed mainly by gastroenterologists (49.5%). They are used in the morning, especially for gastrointestinal symptoms, however, they had been consumed for more than 5 years in 30% of cases. The factors associated with prolonged use are old age (OR 1.03 CI95% 1.01–1.05), body mass index (OR 1.07 CI95% 1.01–1.12), use of non-steroidal anti-inflammatories (OR 3.18 CI95% 1.20–8.43) and selective serotonin reuptake inhibitors (OR 3.5 95% CI 1.39–8.88).

Conclusion

PPIs are adequate in terms of indication and form of use, however, prolonged use associated with old age, being overweight and use of anti-inflammatories and antidepressants is frequent.

Burden of drug use for gastrointestinal symptoms and functional gastrointestinal disorders in France: a national study using reimbursement data for 57 million inhabitants

BACKGROUND

Gastrointestinal therapeutic drugs (GTDs) are extensively prescribed. The aim of this study was to investigate the characteristics of GTD use in a large population: the French general health scheme beneficiaries (87% of the 66 million inhabitants) in 2016.

METHODS

The national health data system was used to identify individual characteristics, diseases and GTD classes reimbursed, together with the costs, using anatomical therapeutic chemical class.

RESULTS

Among the 57.5 million individuals included, 45% received at least one reimbursement among the 130 million prescriptions reimbursed (90% prescribed by a general practitioner): proton-pump inhibitors (PPI; A02BC: 24%), drugs for functional gastrointestinal disorders (A03: 20%), drugs for constipation (A06: 10%), antidiarrheals, intestinal anti-inflammatory/anti-infective agents (A07: 10%), antiemetics and antinauseants (A04: 7%), other drugs for acid-related disorders (A02X: 6%), other drugs for peptic ulcer and gastro-oesophageal reflux disease (A02BX: 4.5%), antacids (A02A: 1.5%). The overall cost of reimbursed GTDs was €707 million and the mean cost per user was €28. Marked variations were observed according to age, sex, and disease. The rates of at least one reimbursement among infants were A07: 28%, A03: 17%, A02BX: 9%, A02X: 7%, A02BC: 6% and A06: 5%. Women more frequently received a reimbursement than men for each GTD class. Reimbursement rates also varied according to health status (end-stage renal disease A02BC: 66%, pregnancy A03: 53%, A04: 11%), treatments (people with at least six reimbursements for nonsteroidal anti-inflammatory drugs in 2016 A02BC: 62%). Chronic GTD use (>10 reimbursements/year) was observed in 19% of people with at least one A02BC reimbursement, A02BX: 11%, A03: 7%, A04: 2%, A06: 17% and A07: 3%.

CONCLUSIONS

This study demonstrates extensive and chronic use of GTD in France, raising the question of their relevance according to current guidelines. They must be disseminated to general practitioners, who are the main prescribers of these drugs.

Predictors of Inappropriate Proton Pump Inhibitors Use in Elderly Patients

Introduction. Overutilization of Proton Pump Inhibitors (PPIs) both in ambulatory care and in the inpatient setting possesses economic implications and increases the risk for adverse drug reactions. This study was undertaken to identify factors associated with inappropriate PPI use among consecutively unplanned admissions of elderly patients at the time of admission. Materials and Methods. In 758 patients (54.2% women), mean age 80.3±8.0 (M±1SD), demographic characteristics, and medical and medication history were recorded. Parametric tests and multiple logistic regression analysis were applied to identify the predictors of inappropriate PPI use. Results. 232 patients (30.6%) were receiving PPIs. 37 (4.9%) were receiving PPIs appropriately and 195 (25.7%) were receiving PPIs without a proper indication. Consequently, PPIs prescribing was inappropriate in 195/232 (84%). Moreover, 512 patients (67.5%) were not receiving PPIs appropriately and 14 patients (1.8%) were not receiving PPIs but they had a proper indication. When we compared patients receiving PPIs without a proper indication with those who were not receiving PPIs, a statistical difference was found according to Charlson Comorbidity Index (p≤0.001, U=37922.00), number of diseases (p≤0.001, U=33269.00) and medications (p≤0.001, U=31218.50), Katz Index score (p=0.01, U=45328.00), and the use of blood thinners (p≤0.001, χ²=21.15). In multivariate analysis the only independent predictor of inappropriate PPI use was the number of medications (p=0.001, OR=1.16, 95%CI 1.06-1.27). Conclusions. The main predictor of inappropriate PPI use was the number of received medications. Εfforts needed to apply the predefined criteria for PPI prescription and to deprescribe PPIs received inappropriately.

Non-guideline-recommended prescribing of proton pump inhibitors: implications for the future and reducing over usage

Drs Godman and Fadare review the paper by Mares-Garcia and colleagues in Spain regarding the extent of non-guideline recommended prescribing (NGRP) of proton pump inhibitors (PPIs) in ambulatory care. NGRP of PPIs is an increasing public health concern given the implications of overuse of PPIs on infection rates, osteoporosis and chronic kidney disease as well as increasing polypharmacy rates. Costs are less of an issue especially where there are low prices for generic PPIs; the main focus is on improving the quality of PPI prescribing. Encouragingly, Mares-Garcia and colleagues identified key factors associated with NGRP, providing direction to others.