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Helgadottir H, Björnsson ES. The Impact of Sex on the Response to Proton Pump Inhibitor Treatment. Pharmaceuticals (Basel) 2023; 16:1722. [PMID: 38139847 PMCID: PMC10747337 DOI: 10.3390/ph16121722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Proton pump inhibitor (PPI) treatment is responsible for substantial gastrin elevation secondary to reduced intragastric acidity. Due to the increasing global prevalence of PPI users, concerns have been raised about the clinical significance of continuous gastrin elevation and its potential long-term side effects. Hypergastrinemia secondary to PPIs has trophic effects on gastric mucosa, leading to enterochromaffin-like cell hyperplasia and gastric (fundic) polyp formation, and it is believed to provoke acid rebound following PPI withdrawal that induces PPI overutilization. Previous studies have found higher gastrin release following PPI therapy in females compared with males, and sex differences have also been demonstrated in pharmacokinetic parameters and dose requirements for acid reflux. It is conceivable that females might be at increased risk of PPI overuse, because they often receive higher milligram-per-kilogram doses. The prevalence of PPI use is more common among females, and the female sex is a risk factor for adverse drug reactions. This non-systematic review outlines the current knowledge of the impact of biological sex on the response to PPIs. The aim is to highlight the female sex as a potential risk factor that could be a step toward precision medicine and should be considered in future research on the response to PPI treatment.
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Affiliation(s)
- Holmfridur Helgadottir
- Department of Internal Medicine, Haraldsplass Diaconal Hospital, 5009 Bergen, Norway;
- Department of Gastroenterology, Haukeland University Hospital, 5009 Bergen, Norway
| | - Einar S. Björnsson
- Department of Gastroenterology, Landspitali University Hospital, 101 Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, 101 Reykjavik, Iceland
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Mari A, Marabotto E, Ribolsi M, Zingone F, Barberio B, Savarino V, Savarino EV. Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future. Expert Rev Clin Pharmacol 2023; 16:913-923. [PMID: 37632213 DOI: 10.1080/17512433.2023.2252327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 08/27/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged. AREAS COVERED In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future. EXPERT OPINION PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.
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Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Nazareth, Israel
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Rome, Italy
| | - Fabiana Zingone
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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PPIs and GI Cancers: Impeached But Likely to Be Acquitted. Am J Gastroenterol 2020; 115:683-684. [PMID: 32167939 DOI: 10.14309/ajg.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this edition of the journal, there is an important nested case-control study from investigators at Kaiser Permanente, Northern California. Proton pump inhibitor exposure for 10 or more years was not associated with any increased risk of gastric cancer. Small observed increased risks of colorectal, hepatocellular, and pancreatic cancers with 10 or more years of exposure are likely to have been spurious. If proton pump inhibitors were to be impeached on the basis of gastrointestinal cancer risk, they are likely to be subsequently acquitted.
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Helgadottir H, Bjornsson ES. Problems Associated with Deprescribing of Proton Pump Inhibitors. Int J Mol Sci 2019; 20:E5469. [PMID: 31684070 PMCID: PMC6862638 DOI: 10.3390/ijms20215469] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023] Open
Abstract
Proton pump inhibitors (PPIs) are recommended as a first-line treatment for gastroesophageal reflux disease (GERD) and other acid related disorders. In recent years, concerns have been raised about the increasing prevalence of patients on long-term PPI therapy and inappropriate PPI use. It is well known that short-term PPI therapy is generally well tolerated and safe; however, their extensive long-term use is a major global issue. One of these long-standing concerns is PPI-induced gastrin elevation secondary to hypoacidity. Hypergastrinemia is believed to play a role in rebound hyperacidity when PPIs are discontinued resulting in induced dyspeptic symptoms that might result in the reinstitution of therapy. Gastrin exerts tropic effects in the stomach, especially on enterochromaffin-like (ECL) cells, and concerns have also been raised regarding the potential progression to dysplasia or tumor formation following long-term therapy. It is well known that a substantial number of patients on long-term PPI therapy can discontinue PPIs without recurrence of symptoms in deprescribing trials. What is unknown is how sustainable deprescribing should be undertaken in practice and how effective it is in terms of reducing long-term outcomes like adverse drug events, morbidity and mortality. Moreover, there is no clear consensus on when and how deprescribing strategies should be attempted in practice. This review sought to summarize the harms and benefits of long-term PPI therapy with special focus on gastrin elevation and its relation to deprescribing studies and future interventions that may improve PPI use.
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Affiliation(s)
- Holmfridur Helgadottir
- Faculty of Medicine, University of Iceland, 101 Reykjavik, Iceland.
- Division of Gastroenterology and Hepatology, The National University Hospital of Iceland, 101 Reykjavik, Iceland.
| | - Einar S Bjornsson
- Faculty of Medicine, University of Iceland, 101 Reykjavik, Iceland.
- Division of Gastroenterology and Hepatology, The National University Hospital of Iceland, 101 Reykjavik, Iceland.
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Klenzak S, Danelisen I, Brannan GD, Holland MA, van Tilburg MAL. Management of gastroesophageal reflux disease: Patient and physician communication challenges and shared decision making. World J Clin Cases 2018; 6:892-900. [PMID: 30568943 PMCID: PMC6288517 DOI: 10.12998/wjcc.v6.i15.892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/16/2018] [Accepted: 11/24/2018] [Indexed: 02/05/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common upper esophageal condition and typical symptoms can include heartburn and sensation of regurgitation while atypical symptoms include chronic cough, asthma, hoarseness, dyspepsia and nausea. Typically, diagnosis is presumptive given the presence of typical and atypical symptoms and is an indication for empiric therapy. Treatment management can include lifestyle modifications and/or medication therapy with proton pump inhibitor (PPI) class being the preferred and most effective. Complete symptom resolution is not always achieved and long-term PPI therapy can put patients at risk for serious side effects and needless expense. The brain-gut connection and hypervigilance plays an important role in symptom resolution and treatment success, especially in the case of non-PPI responders. Hypervigilance is a combination of increased esophageal sensory sensitivity in combination with exaggerated threat perception surrounding esophageal symptoms. Hypervigilance requires a different approach to GERD managements, where continued PPI therapy and surgery are usually not recommended. Rather, helping physicians and patients understand the brain-gut connection can guide and improve care. Education and reassurance should be the main pillars or treatment. However, it is important not to suggest the symptoms are due to anxiety alone, this often leads to patient dissatisfaction. Patient dissatisfaction with treatment reveals the need for a more patient-centered approach to GERD management and better communication between patients and providers. Shared decision making (SDM) with the incorporation of patient-reported outcomes (PRO) promotes patient adherence and satisfaction. SDM is a joint discussion between clinician and patient in which a mutually shared solution is explored for GERD symptoms. For SDM to work the physician needs to capture patients’ perceptions which may not be obtained in the standard interview. This can be done through the use of PROs which promote a dialogue with patients about their symptoms and treatment priorities in the context of the SDM patient encounter. SDM could potentially help in the management of patient expectations for GERD treatment, ultimately positively impacting their health-related quality of life.
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Affiliation(s)
- Scott Klenzak
- Department of Psychiatry, Cape Fear Valley Health System, Fayetteville, NC 28304, United States
| | - Igor Danelisen
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, United States
| | - Grace D Brannan
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, United States
| | - Melissa A Holland
- College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC 27506, United States
| | - Miranda AL van Tilburg
- College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC 27506, United States
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
- University of Washington, Seattle, WA 98105, United States
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Study of Gender Differences in Proton Pump Inhibitor Dose Requirements for GERD: A Double-Blind Randomized Trial. J Clin Gastroenterol 2017; 51:486-493. [PMID: 27159420 DOI: 10.1097/mcg.0000000000000542] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
GOALS To determine the proportion of patients with gastroesophageal reflux disease who are on proton pump inhibitors (PPIs) who could reduce their prior dosage by half, and identify predictors of successful step-down. BACKGROUND Appropriate hypergastrinemia results from gastric acid inhibition. A gender difference in fasting gastrin with higher levels among women than among men on long-term PPI therapy has been demonstrated. STUDY Patients with endoscopically verified erosive esophagitis on long-term PPI therapy were randomized double blindly to step down their dose by half or continue with the same dose for 8 weeks. Fasting gastrin levels were measured before and after treatment. The primary endpoint was successful step-down throughout the study period. RESULTS Overall, 100 patients were randomized, 49 (24 females) to continue with the same dose as before and 51 (25 females) to step down. Female patients had higher gastrin levels compared with male patients: 78 pg/mL (IQR, 50 to 99) versus 50 pg/mL (IQR, 36 to 74) (P=0.007). Among those randomized to the step-down intervention only 3/25 (12%) women failed to complete the 2 months of lower-dose therapy versus 9/25 (36%) men (P=0.09). Female gender (P=0.048) was the strongest predictor for successful step-down (odds ratio=1.27; 95% CI, 1.01-1.60). The chance of failing to maintain symptom control was twice as high in the reduction group (24%) as compared with the control group (13%) (P=0.2). CONCLUSIONS Female patients on long-term PPI therapy were 3 times more likely to tolerate half of their prior dose. Female gender had higher probability for successful step-down. These results indicate that women with gastroesophageal reflux disease might manage with lower doses of PPIs as compared with men.European Clinical Trial Database (https://eudract.ema.europa.eu/), number 2013-002067-26.
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Lee C, Lo A, Ubhi K, Milewski M. Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site: Quality Improvement Project. Can J Hosp Pharm 2017; 70:215-223. [PMID: 28680175 DOI: 10.4212/cjhp.v70i3.1661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Increased prescribing of proton pump inhibitors (PPIs) in the past few decades can be attributed mainly to long-term use of this type of therapy. Recent evidence indicates signals of harm associated with long-term use of PPIs, such as increased risk of Clostridium difficile infection, recurrence of C. difficile infection, and fracture. A few studies have assessed the effectiveness of step-down management of patients receiving long-term PPI therapy in ambulatory care settings. However, it is unknown whether PPIs can be discontinued in older people without return of gastrointestinal symptoms. OBJECTIVES To determine the proportion of residents receiving long-term PPI therapy who were able to discontinue the drug without experiencing gastrointestinal symptoms warranting recommencement of the PPI or initiation of a histamine-2 receptor antagonist. METHODS The records of residents who had been taking a PPI for longer than 6 months at a single residential care site were audited by one pharmacist to determine the PPI indication. For residents who fit the criteria for discontinuation (no indication for long-term PPI therapy, not currently experiencing gastrointestinal symptoms, no previous trial of PPI discontinuation without success, and no anxiety when medications are discontinued), the pharmacist faxed a recommendation to discontinue PPI therapy without tapering to the physicians' offices. For cases in which the recommendation was accepted, 3 pharmacists followed the residents weekly for 8 weeks to assess whether gastrointestinal symptoms returned. RESULTS The pharmacist identified 28 residents who fit the criteria, and the recommendation to discontinue therapy was accepted for 27. At 8 weeks after the intervention, 19 (70%) of these residents were still asymptomatic and did not require re-initiation of medications to manage their gastrointestinal symptoms. CONCLUSIONS These results support discontinuation of long-term PPI therapy for older people who fit the criteria for discontinuation. The study provided limited evidence to support the use of tapering. However, tapering can be used to identify the lowest effective dose and may increase patient comfort with deprescribing. Further research is needed to determine the effects of and best approaches to PPI discontinuation in older populations.
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Affiliation(s)
- Candy Lee
- BScPharm, is a Pharmacist with Ridge Meadows Hospital, Maple Ridge, British Columbia
| | - Anita Lo
- BScPharm, PharmD, is a Clinical Pharmacy Specialist with Baillie House, Ridge Meadows Hospital, Maple Ridge, British Columbia
| | - Kiran Ubhi
- BSP, PharmD, is a Clinical Pharmacy Specialist with Baillie House, Ridge Meadows Hospital, Maple Ridge, British Columbia
| | - Michael Milewski
- MD, is the Medical Director at Baillie House, Ridge Meadows Hospital, Maple Ridge, British Columbia
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Yadlapati R, Dakhoul L, Pandolfino JE, Keswani RN. The Quality of Care for Gastroesophageal Reflux Disease. Dig Dis Sci 2017; 62:569-576. [PMID: 28028689 PMCID: PMC5768307 DOI: 10.1007/s10620-016-4409-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/06/2016] [Indexed: 12/14/2022]
Abstract
Improving the quality of healthcare delivery is a cornerstone of modern medical care shared between all stakeholders. However, effectively improving quality requires both an understanding of the tenets of healthcare quality and how they relate to an individual disease process. This is especially important for common diseases, such as gastroesophageal reflux disease (GERD), where wide variations in practice exist. The high prevalence of GERD coupled with wide variation in clinical approach results in significant economic burden and poor quality of care. Thus, GERD serves as a useful framework to highlight the opportunities and current challenges of delivering high-quality care. In this article, we identify quality metrics in GERD and the areas in need of research to improve the quality of the management of GERD. Additionally, we suggest strategies for improvement as it relates to the proper diagnostic testing utilization and the decision-making process.
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Affiliation(s)
- Rena Yadlapati
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lara Dakhoul
- University of Illinois, Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - John E. Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rajesh N. Keswani
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Radomski TR, Good CB, Thorpe CT, Zhao X, Marcum ZA, Glassman PA, Lowe J, Mor MK, Fine MJ, Gellad WF. Variation in Formulary Management Practices Within the Department of Veterans Affairs Health Care System. J Manag Care Spec Pharm 2015; 22:114-20. [PMID: 27015250 PMCID: PMC7024562 DOI: 10.18553/jmcp.2016.14251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND All Department of Veterans Affairs Medical Centers (VAMCs) operate under a single national drug formulary, yet substantial variation in prescribing and spending exists across facilities. Local management of the national formulary may differ across VAMCs and may be one cause of this variation. OBJECTIVE To characterize variation in the management of nonformulary medication requests and pharmacy and therapeutics (P&T) committee member perceptions of the formulary environment at VAMCs nationwide. METHODS We performed an online survey of the chief of pharmacy and an additional staff pharmacist and physician on the P&T committee at all VAMCs. Respondents were asked questions regarding criteria for use for nonformulary medications, specific procedures for ordering nonformulary medications in general and specific lipid-lowering and diabetes agents, the appeals process, and the formulary environment at their VAMCs. We compared responses across facilities and between chiefs of pharmacy, pharmacists, and physicians. RESULTS A total of 212 chief pharmacists (n = 80), staff pharmacists (n = 78), and physicians (n = 54) responded, for an overall response rate of 49%. In total, 107/143 (75%) different VAMCs were represented. The majority of VAMCs reported adhering to national criteria for use, with 38 (36%) being very adherent and 69 (65%) being mostly adherent. There was substantial variation between VAMCs regarding how nonformulary drugs were ordered, evaluated, and appealed. The nonformulary lipid-lowering drugs ezetimibe, rosuvastatin, and atorvastatin were viewable to providers in the order entry screen at 67 (63%), 67 (63%), and 64 (60%) VAMCs, respectively. The nonformulary diabetes medication pioglitazone was only viewable at 58 (55%) VAMCs. In the remaining VAMCs, providers could not order these nonformulary drugs through the normal order-entry process. For questions about the formulary environment, physician respondent perceptions differed from those of staff pharmacists and chief pharmacists. Compared with pharmacy chiefs and staff pharmacists, physicians were less likely to agree that providers at their VAMC prescribed too many nonformulary medications (47% and 44% vs. 12%, P < 0.001), more likely to agree that providers must jump through too many hoops to prescribe nonformulary medication (5% and 3% vs. 25%, P < 0.001), and more likely to agree that providers make an effort to convert new patients from nonformulary to formulary lipid-lowering (65% and 73% vs. 94%, P <0.02) and diabetic medications (49% and 50% vs. 88%, P < 0.001). CONCLUSIONS Although the Department of Veterans Affairs (VA) operates under a single national formulary, we found significant differences among VAMCs regarding their management of nonformulary medication requests. We also found differences among formulary leaders regarding their perception of the environment in which their VAMC's formulary is managed. These findings have important implications not just for VA, but for any organization that develops, implements, and manages drug formularies across multiple facilities.
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Affiliation(s)
- Thomas R Radomski
- 1 Clinical Instructor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Clinical Research Fellow, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Chester B Good
- 2 Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine; Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy; Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Chair, Medical Advisory Panel, and Co-director, VA Center for Medication Safety, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Carolyn T Thorpe
- 3 Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Assistant Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- 4 Statistician, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Zachary A Marcum
- 5 Assistant Professor, Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Peter A Glassman
- 6 Staff Physician, VA Greater Los Angeles Healthcare System; Professor of Clinical Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; and Chair, Medical Advisory Panel, and Co-director, VA Center for Medication Safety, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - John Lowe
- 7 Associate Chief Consultant, Pharmacy Compliance and Efficiency, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Maria K Mor
- 8 Director, Biostatistics and Informatics Core, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Research Assistant Professor, Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J Fine
- 9 Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Director, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- 10 Associate Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Gawron AJ, Pandolfino J, Miskevics S, LaVela SL. Initial proton pump inhibitor characteristics associated with long-term prescriptions in US veterans diagnosed with gastro-oesophageal reflux disease. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2014. [DOI: 10.1111/jphs.12057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Andrew J. Gawron
- Division of Gastroenterology and Hepatology; Feinberg School of Medicine; Northwestern University; Chicago USA
- Center for Healthcare Studies; Feinberg School of Medicine; Northwestern University; Chicago IL USA
- Health Services Research and Development; Department of Veterans Affairs; Edward Hines Jr. VA Hospital; Hines IL USA
| | - John Pandolfino
- Division of Gastroenterology and Hepatology; Feinberg School of Medicine; Northwestern University; Chicago USA
| | - Scott Miskevics
- Health Services Research and Development; Department of Veterans Affairs; Edward Hines Jr. VA Hospital; Hines IL USA
| | - Sherri L. LaVela
- Center for Healthcare Studies; Feinberg School of Medicine; Northwestern University; Chicago IL USA
- Health Services Research and Development; Department of Veterans Affairs; Edward Hines Jr. VA Hospital; Hines IL USA
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Mody R, Eisenberg D, Hou L, Kamat S, Singer J, Gerson LB. Comparison of health care resource utilization and costs among patients with GERD on once-daily or twice-daily proton pump inhibitor therapy. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:161-9. [PMID: 23637544 PMCID: PMC3639021 DOI: 10.2147/ceor.s41189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess differences in health care resource utilization and costs associated with once-daily and twice-daily proton pump inhibitor (PPI) therapy. Most patients with gastroesophageal reflux disease (GERD) achieve symptom control on once-daily PPI therapy, but approximately 20%-30% require twice-daily dosing. METHODS Patients were ≥18 years of age with at least one medical claim for GERD and at least two PPI claims from HealthCore's Integrated Research Database (HIRD(SM)) during 2004-2009. Patients were continuously eligible for 12 months before and after the index date (date of first PPI claim). Based on PPI dosing throughout the post-index period (quantity of medication dispensed/number of days supply), patients were classified as once-daily (dose ≤ 1.5 pills per day) or twice-daily (≥1.5) PPI users. RESULTS The study cohort included 248,386 patients with GERD (mean age 52.8 ± 13.93 years, 56% females) of whom 90% were once-daily and 10% were twice-daily PPI users. The Deyo-Charlson Comorbidity Index for once-daily and twice-daily PPI users was 0.70 ± 1.37 and 0.89 ± 1.54, respectively (P < 0.05). More once-daily patients had claims for Barrett's esophagus (5% versus 2%, P < 0.0001) than twice-daily patients. Post-index, higher proportions of twice-daily patients had at least one GERD-related inpatient visit (7% versus 5%), outpatient visit (60% versus 49%), and office visit (48% versus 38%) versus once-daily patients (P < 0.0001). Mean total GERD-related health care costs were $2065 ± $6636 versus $3749 ± $11,081 for once-daily and twice-daily PPI users, respectively (P < 0.0001). CONCLUSION Patients receiving twice-daily PPI therapy were likely to have more comorbid conditions and greater health care utilization and overall costs compared with patients using once-daily PPI therapy.
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Affiliation(s)
- Reema Mody
- Takeda Pharmaceuticals International Inc, Deerfield, IL
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12
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Fass R, Inadomi J, Han C, Mody R, O'Neil J, Perez MC. Maintenance of heartburn relief after step-down from twice-daily proton pump inhibitor to once-daily dexlansoprazole modified release. Clin Gastroenterol Hepatol 2012; 10:247-53. [PMID: 22155561 DOI: 10.1016/j.cgh.2011.11.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/14/2011] [Accepted: 11/28/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Many patients with gastroesophageal reflux disease (GERD) take a proton pump inhibitor (PPI) twice daily to control symptoms. Once-daily dexlansoprazole modified release (MR) has a dual-delayed release formulation, making it attractive for step-down management of patients whose symptoms are well controlled on twice-daily PPIs. We investigated whether step-down to once-daily dexlansoprazole controls heartburn in patients with GERD who were receiving twice-daily PPI therapy. METHODS Patients 18 years and older taking a twice-daily PPI for symptom control were enrolled (n = 178) in a single-blind, multicenter study; 163 patients completed the study and 142 patients met criteria for the efficacy analysis. During the 6-week screening and treatment periods, patients recorded the presence of heartburn symptoms twice daily in electronic diaries. Patients' heartburn was considered well controlled if they had an average of 1 symptom or fewer per week during the last 4 weeks of screening and treatment. After screening, qualified patients were switched to masked dexlansoprazole MR 30 mg and placebo for 6 weeks. The primary efficacy end point was the proportion of patients whose heartburn remained well controlled after step-down. GERD-related symptoms and quality of life (QOL) also were evaluated using the Patient Assessment of Upper Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM) and the PAGI-QOL questionnaires, respectively. RESULTS After step-down to once-daily dexlansoprazole MR 30 mg, heartburn remained well controlled in 88% of patients (125 of 142). These patients were able to maintain their GERD-related symptom severity and QOL, indicated by marginal changes in the PAGI-SYM and PAGI-QOL total and subscale scores, respectively. CONCLUSIONS Most patients with GERD who take twice-daily PPI to control heartburn are able to successfully step down to once-daily dexlansoprazole 30 mg.
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Affiliation(s)
- Ronnie Fass
- Section of Gastroenterology, Southern Arizona VA Healthcare System, Tucson, Arizona 85723, USA.
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Acid suppression for reflux disease: "off-the-peg" or a tailored approach? Clin Gastroenterol Hepatol 2012; 10:210-3. [PMID: 22138274 DOI: 10.1016/j.cgh.2011.11.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 11/10/2011] [Indexed: 02/07/2023]
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Bruley des Varannes S, Coron E, Galmiche JP. Short and long-term PPI treatment for GERD. Do we need more-potent anti-secretory drugs? Best Pract Res Clin Gastroenterol 2010; 24:905-21. [PMID: 21126703 DOI: 10.1016/j.bpg.2010.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 09/17/2010] [Accepted: 09/20/2010] [Indexed: 02/06/2023]
Abstract
Because the reflux of the acidic gastric content into the esophagus plays a major role in the pathogenesis of symptoms of GERD and lesions of erosive esophagitis, acid suppression with a proton pump inhibitor (PPI) is currently the mainstay of anti-reflux therapy. There is a strong correlation between the degree of acid suppression provided by a given drug and its efficacy. The superiority of PPIs over other drugs (antacids, prokinetics and H(2)-receptor antagonists) has now been established beyond doubt, both for short- and long-term treatment. However, there are still some unmet therapeutic needs in GERD; hence, patients with non-erosive reflux disease (NERD) are less responsive to PPIs than those with erosive esophagitis. Moreover, the efficacy of PPIs in patients with atypical symptoms is frequently limited to the relief of associated heartburn or regurgitation. With respect to safety, although most studies on short- and long-term PPI use have provided reassuring data, recent reports have drawn attention to potential side effects or drug-drug interference. Better healing rates in the most severe forms of esophagitis, or a faster onset of symptom relief, may require optimization of acid suppressive therapy with regard to the daily course of acid secretion, especially during the night. Different pharmacological approaches can be considered, with the ultimate goals of achieving faster, stronger and more-sustained acid inhibition. How a better pharmacological profile may translate into clinical benefit should now be tested in appropriate, controlled studies.
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Abstract
Two recent studies-one of which is published in this edition of the American Journal of Gastroenterology-have reported that new dyspeptic or reflux symptoms may develop among previously asymptomatic individuals after withdrawal of a short course of a proton pump inhibitor (PPI). It has been suggested that this is attributable to rebound gastric acid hypersecretion, and that the same phenomenon explains why some patients become chronic PPI users and physicians experience "difficulty" in withdrawing PPI treatment from patients. Although we congratulate the authors of both studies for their controlled observations, we question the generalizability of these observations and hypotheses to the clinical domain. PPI treatment continues to be the optimal management strategy for most patients with gastroesophageal reflux disease and is indicated for chronic use as ulcer prophylaxis in nonsteroidal anti-inflammatory drug takers at high risk for bleeding. However, as with all drugs, PPIs should be dosed appropriately, and should be reserved for patients with conditions for which there is clear evidence of benefit from therapy.
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Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1392-1413, 1413.e1-5. [PMID: 18801365 DOI: 10.1053/j.gastro.2008.08.044] [Citation(s) in RCA: 245] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Peter J Kahrilas
- Department of Medicine, Gastroenterology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Pallotta S, Pace F, Marelli S. Rabeprazole: a second-generation proton pump inhibitor in the treatment of acid-related disease. Expert Rev Gastroenterol Hepatol 2008; 2:509-22. [PMID: 19072398 DOI: 10.1586/17474124.2.4.509] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Rabeprazole is a proton pump inhibitor (PPI) presenting a very advantageous pharmacodynamic and pharmacokinetic profile over older PPIs. In particular, this drug has a very fast onset of action, due to a short activation time and a very high pKa, and may therefore be defined as a 'second generation' PPI. The aim of this article is to provide an update on the pharmacology and clinical profile of rabeprazole and its use in acid-related disorders, with a particular focus on its role in gastroesophageal reflux disease; in the treatment and prevention of duodenal and gastric ulcers and Zollinger-Ellison syndrome; in the therapy of the extraesophageal manifestations of gastroesophageal reflux disease (in particular the respiratory and ear, nose and throat ones); and in the eradication of Helicobacter pylori.
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Affiliation(s)
- Stefano Pallotta
- University of Milan, Via GB Grassi, 74, 20157 Milano, MI, Italy.
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Abstract
Proton pump inhibitors (PPIs) have revolutionized the management of gastroesophageal reflux disease and peptic ulcer disease over the past two decades. Among the most commonly prescribed agents worldwide, PPIs' overall safety profile is unquestionable. However, emerging evidence indicates that PPI therapy, particularly with long-term and/or high-dose administration, is associated with several potential adverse effects, including enteric infections (eg, Clostridium difficile), community-acquired pneumonia, and hip fracture, all of which have received much attention recently. We review the current data on these and other potential consequences of PPI therapy. More judicious use of PPIs (eg, administering them in no more than the minimum effective dose to older adult patients) may help to further limit the impact of some of these possible adverse effects.
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Affiliation(s)
- Gregory A Coté
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611, USA
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Bibliography. Current world literature. Laryngology and bronchoesophagology. Curr Opin Otolaryngol Head Neck Surg 2007; 15:417-24. [PMID: 17986882 DOI: 10.1097/moo.0b013e3282f3532f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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