Proton pump inhibitors: misconceptions and proper prescribing practice

Safe use of proton-pump inhibitors

Proton pump inhibitors (PPIs) are one of the most commonly prescribed drug groups in developed countries. Their approved indications include gastroesophageal reflux disease, peptic ulcer disease, and prophylaxis against NSAID-induced gastroenteropathy in specific scenarios. Since their introduction into clinical practice, their usage has significantly increased, leading to concerns about possible inappropriate prescribing, which can result in a higher risk of side effects and increased economic costs. Consequently, in recent years, literature linking PPIs to various adverse effects has emerged, with some supported by robust evidence, while others are based on lower-quality evidence, requiring cautious interpretation. Among the adverse effects of PPIs, significant ones include an increased risk of fragility fractures, deficiencies in certain micronutrients such as vitamin B12 and magnesium, a higher incidence of enteric infections, especially Clostridioides difficile, complications in cirrhotic patients, and pharmacological interactions with other medications. In clinical practice, it is essential to periodically evaluate the rationale for prescribing these drugs and consider discontinuing them if there is no appropriate indication. Despite PPIs being generally safe medications, it is crucial to be aware of their potential adverse effects and appropriate indications to ensure their proper use.

Knowledge, attitude, and practices regarding proton pump inhibitors among community pharmacists and pharmacy students

Background

There are concerns about inappropriate use and insufficient knowledge of proton pump inhibitors (PPIs) use among medical staff.

Aims

This study was designed to examine pharmacy students' and community pharmacists' knowledge, attitude, and practices toward PPIs and their relationship with specific sociodemographic characteristics.

Subjects and Methods

This descriptive study was conducted on the pharmacy students (first and last year) at Eastern Mediterranean University and community pharmacists in North Cyprus Data were collected by a validated questionnaire, which assessed knowledge, attitude, and practices regarding PPI use. Students were included without sampling in a volunteer-based manner. Registered community pharmacists were selected randomly.

Results

First-year pharmacy students (n = 77) showed significantly lower knowledge levels than last-year students (12.00 vs. 13.65; P < 0.001); however, there was no significant difference between last-year students (n = 111) and community pharmacists (n = 59). First-year pharmacy students were significantly less aware of PPIs' "dosage and administration" than the other two groups. Last-year students and community pharmacists exhibited significantly higher attitude scores regarding PPI use (24.7 and 24.6 vs. 22.7; P < 0.001). Omeprazole was found to be the most preferred PPI among the three studied populations. Community pharmacists used PPIs mainly to treat acid reflux. Gender, nationality, and pharmacy education program type did not influence pharmacy students' knowledge, attitude, or practices.

Conclusions

There was not a significant difference regarding knowledge and attitude between the last-year pharmacy students and community pharmacists. The practices of community pharmacists were significantly different from the pharmacy students. It was concluded that certain essential topics regarding PPI use should be emphasized in pharmacy education and during pharmacy practice. Further, it is essentially important for community pharmacists to continue their education through training programs after graduation to enhance their knowledge of PPI use.

People exposed to proton-pump inhibitors shortly preceding COVID-19 diagnosis are not at an increased risk of subsequent hospitalizations and mortality: A nationwide matched cohort study

AIMS

To assess whether exposure to proton-pump inhibitors (PPIs) shortly preceding COVID-19 diagnosis affected the risk of subsequent hospitalizations and mortality.

METHODS

This population-based study embraced first COVID-19 episodes in adults diagnosed up to 15 August 2021 in Croatia. Patients were classified based on exposure to PPIs and burden of PPI-requiring morbidities as nonusers (no issued prescriptions, no recorded treatment-requiring conditions between 1 January 2019 and COVID-19 diagnosis), possible users (no issued prescriptions, but morbidities present; self-medication possible) and users (≥1 prescription within 3 months prior to the COVID-19 diagnosis; morbidities present). Subsets were mutually exactly matched for pre-COVID-19 characteristics. The contrast between users and possible users informed about the effect of PPIs that is separate of the effect of PPI-requiring conditions.

RESULTS

Among 433 609 patients, users and possible users were matched 41 195 (of 55 098) to 17 334 (of 18 170) in the primary and 33 272 to 16 434 in the sensitivity analysis. There was no relevant difference between them regarding mortality (primary: relative risk [RR] = 0.93 [95% confidence interval 0.85-1.02; absolute risk difference [RD] = -0.34% [-0.73, 0.03]; sensitivity: RR = 0.88 [0.78-0.98]; RD = -0.45% [-0.80, -0.11]) or hospitalizations (primary: RR = 1.04 [0.97-1.13]; RD = 0.29% [-0.16, 0.73]; sensitivity: RR = 1.05 [0.97-1.15]; RD = 0.32% [-0.12, 0.75]). The risks of both were slightly higher in possible users or users than in nonusers (absolutely by ~0.4-1.6%) indicating the effect of PPI-requiring morbidities.

CONCLUSION

Premorbid exposure to PPIs does not affect the risk of death or hospitalization in adult COVID-19 patients, but PPI-requiring morbidities seemingly slightly increase the risk of both.

Prescribing trends of proton pump inhibitors, antipsychotics and benzodiazepines of medicare part d providers

Background

Proton pump inhibitors, benzodiazepines, and antipsychotics are considered potentially inappropriate medications in older adults according to the American Geriatric Society Beers Criteria, and deprescribing algorithms have been developed to guide use of these drug classes. The objective of this study was to describe the number of beneficiaries prescribed these medications, provider specialty and regional trends in prescribing, and the aggregate costs for these claims in Medicare Part D.

Methods

This was a retrospective cross-sectional study using publicly available Medicare Provider Utilization and Payment Data: Part D Prescriber data for years 2013–2019. Descriptive statistics and the Cochrane-Armitage test were used to summarize the trends.

Results

Overall, 30.1%, 25.6%, 4.6% of Medicare Part D beneficiaries had a proton pump inhibitor, benzodiazepine, and antipsychotic claim in 2013, respectively. These rates decreased to 27.5%, 17.5%, 4.1% in 2019 (p-value < 0.0001). However, the number of standardized 30-day claims increased from 63 million in 2013 to 84 million in 2019 for proton pump inhibitors, remained steady for benzodiazepines and slightly increased (10 million to 13 million) for antipsychotics. Total aggregate costs decreased by almost $1.5 billion for proton pump inhibitor, $100 million for benzodiazepine, and $700 million for antipsychotic from 2013 to 2019 (p-value < 0.0001). Almost 93% of gastroenterologists prescribed a proton pump inhibitor, and 60% of psychiatrists prescribed benzodiazepines and antipsychotics all seven years. The Other region had the highest percentage of providers prescribing all three classes and the highest number of standardized 30-day benzodiazepine claims.

Conclusions

The overall rate of use of proton pump inhibitors, benzodiazepines, and antipsychotics decreased from 2013–2019 among Medicare Part D beneficiaries. Despite the increase in raw number of standardized 30-day claims, the costs decreased which is likely due to generics made available. These prescribing trends may aid in identifying and targeting potential deprescribing interventions.

Common Pitfalls in the Management of Patients with Micronutrient Deficiency: Keep in Mind the Stomach

Micronutrient deficiencies are relatively common, in particular iron and cobalamin deficiency, and may potentially lead to life-threatening clinical consequences when not promptly recognized and treated, especially in elderly patients. The stomach plays an important role in the homeostasis of some important hematopoietic micronutrients like iron and cobalamin, and probably in others equally important such as ascorbic acid, calcium, and magnesium. A key role is played by the corpus oxyntic mucosa composed of parietal cells whose main function is gastric acid secretion and intrinsic factor production. Gastric acid secretion is necessary for the digestion and absorption of cobalamin and the absorption of iron, calcium, and probably magnesium, and is also essential for the absorption, secretion, and activation of ascorbic acid. Several pathological conditions such as Helicobacter pylori-related gastritis, corpus atrophic gastritis, as well as antisecretory drugs, and gastric surgery may interfere with the normal functioning of gastric oxyntic mucosa and micronutrients homeostasis. Investigation of the stomach by gastroscopy plus biopsies should always be considered in the management of patients with micronutrient deficiencies. The current review focuses on the physiological and pathophysiological aspects of gastric acid secretion and the role of the stomach in iron, cobalamin, calcium, and magnesium deficiency and ascorbate homeostasis.