Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care

Proton Pump Inhibitors: Rational Use and Use-Reduction - The Windsor Workshop

BACKGROUND

Despite deprescribing initiatives to curb overutilization of proton pump inhibitors (PPIs), achieving meaningful reductions in PPI use is proving a challenge.

SUMMARY

An international group of primary care doctors and gastroenterologists examined the literature surrounding PPI use and use-reduction to clarify: (i) what constitutes rational PPI prescribing; (ii) when and in whom PPI use-reduction should be attempted; and (iii) what strategies to use when attempting PPI use-reduction.

KEY MESSAGES

Before starting a PPI for reflux-like symptoms, patients should be educated on potential causes and alternative approaches including dietary and lifestyle modification, weight loss, and relaxation strategies. When commencing a PPI, patients should understand the reason for treatment, planned duration, and review date. PPI use at hospital discharge should not be continued without a recognized indication for long-term treatment. Long-term PPI therapy should be reviewed at least annually. PPI use-reduction should be based on the lack of a rational indication for long-term PPI use, not concern for PPI-associated adverse events. PPI use-reduction strategies involving switching to on-demand PPI or dose tapering, with rescue therapy for rebound symptoms, are more likely to succeed than abrupt cessation.

Mediation analysis with case-control sampling: Identification and estimation in the presence of a binary mediator

With reference to a stratified case-control (CC) procedure based on a binary variable of primary interest, we derive the expression of the distortion induced by the sampling design on the parameters of the logistic model of a secondary variable. This is particularly relevant when performing mediation analysis (possibly in a causal framework) with stratified case-control (SCC) data in settings where both the outcome and the mediator are binary. Despite being designed for parametric identification, our strategy is general and can be used also in a nonparametric context. With reference to parametric estimation, we derive the maximum likelihood (ML) estimator and the M-estimator of the joint outcome-mediator parameter vector. We then conduct a simulation study focusing on the main causal mediation quantities (i.e., natural effects) and comparing M- and ML estimation to existing methods, based on weighting. As an illustrative example, we reanalyze a German CC data set in order to investigate whether the effect of reduced immunocompetency on listeriosis onset is mediated by the intake of gastric acid suppressors.

Are Proton Pump Inhibitors Contributing in Emerging New Hypertensive Population?

Balancing the therapeutic advantages of a medicine with its possible risks and side effects is an important part of medical practice and drug regulation. When a drug is designed to treat a particular disease or medical condition ends up causing additional risks or side effects that lead to the development of other serious health problems, it can have detrimental consequences for patients. This article explores the correlation between persistent proton pump inhibitor (PPI) use and hypertension, a common cardiovascular ailment. While PPIs are beneficial in treating various gastrointestinal problems, their availability without a prescription has resulted in self-medication and long-term use without medical monitoring. Recent findings have revealed a link between long-term PPI usage and increased cardiovascular risks, particularly hypertension. This study investigates the intricate mechanisms underlying PPI's effects, focusing on potential pathways contributing to hypertension, such as endothelial dysfunction, disruption of nitric oxide bioavailability, vitamin B deficiency, hypocalcemia, and hypomagnesemia. The discussion explains how long-term PPI use can disrupt normal endothelial function, vascular control, and mineral balance, eventually leading to hypertension. The article emphasizes the significance of using PPIs with caution and ongoing research to better understand the implications of these medications on cardiovascular health.

Inappropriate proton-pump inhibitor prescribing in primary care - an observational study with quality circles

INTRODUCTION

Proton-pump inhibitors (PPIs) should be deprescribed when an indication is lacking or the dose is too high. Academic and media reports have tried to raise awareness and thereby reduce the inappropriate prescribing of PPIs. However, pharmacoepidemiologic studies have shown an unchanged frequency of such inappropriate prescribing over time. Little is known about whether or how general practitioners (GPs) adapt their prescribing practices once their awareness of inappropriate PPI prescribing has been raised.

OBJECTIVE

We aimed to investigate the prevalence of potentially inappropriate PPI prescribing (too high dose or no indication) in a consecutive sample of patients in Swiss primary care settings. Our goal was then to evaluate how GPs managed the patients with potentially inappropriate PPI prescribing over 12 months after flagging these patients.

METHODS

In this observational study, 11 GPs from the canton of Bern in Switzerland used their medical records to identify 20 patients who had been prescribed a PPI for ≥8 weeks and flagged potentially inappropriate PPI prescribing in their records. After 12 months, we asked the same GPs whether the PPI prescriptions of those patients had changed and, if so, how.

RESULTS

Of 1,376 patients consecutively screened, 206 (15%) had been prescribed a PPI for ≥8 weeks. Of these 206 patients, 85 (41%) had a potentially inappropriate PPI prescription. Of these 85 patients, 55 (65%) had no indication for PPI, and 30 (35%) had a too-high dose. After one year, only 29 (35%) of the 84 flagged potentially inappropriate PPIs were stopped or reduced. The most frequently mentioned reasons that deprescribing was not possible were a lack of discussion with the patient (no contact or no time), the presence of symptoms requiring the PPI, or the unwillingness of the patient to deprescribe.

CONCLUSION

In the Swiss primary care setting, the rate of potentially inappropriate PPI prescribing is high. Having GPs flag potentially inappropriate PPI prescribing did not result in PPI deprescribing in most patients over 12 months. Our findings suggest that more personalised and targeted interventions are necessary to successfully implement the deprescribing of potentially inappropriate PPIs. We see the need to co-design interventions with patients and providers and test behavioural change techniques to enable the deprescribing of inappropriate PPIs.

Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future

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.

Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients

Background

Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences.

Objective

To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST.

Methods

This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified.

Results

During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007).

Conclusion

This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.

Analysis of deprescription strategies of proton pump inhibitors in primary care: a narrative review

BACKGROUND

Since the introduction of omeprazole in 1989, proton pump inhibitors (PPIs) have become the mainstream of treatment for acid-related pathologies, but nowadays, it is estimated that between 20% and 80% of people worldwide who are using PPIs are doing so without an approved indication. Overusing PPIs is known to involve a tremendous cost in financial terms, and many western countries have reported high spending on these medicines.

OBJECTIVE

We conducted a narrative review to evaluate PPI deprescription strategies carried out entirely or in collaboration with primary care and to identify factors that could influence the success of these strategies.

METHOD

This review was conducted in November 2022, following PRISMA guidelines. Four databases were searched: PubMed, Web of Science, Scopus and CINAHL Complete, using the MeSH terms 'proton pump inhibitors' AND 'deprescriptions'.

RESULTS

The search with the established criteria found eight studies. The different success rates obtained by the various studies analysed in this review may be due to the different methodologies used when establishing the protocols, sample selection and monitoring of the results.

CONCLUSION

We can conclude that the two factors related to the most successful strategies were a) the clarity and simplicity of the de-escalation protocols, in which patients were instructed on the measures to follow in the event of the reappearance of symptoms, and b) the training of the physicians responsible for deprescribing. Long-term conclusions cannot be drawn about the effectiveness of these protocols, given that the studies are limited in time. Other barriers to generalizing the results are the small sample size and the absence of control groups.

Appropriateness of the Prescription and Use of Medicines: An Old Concept but More Relevant than Ever

The availability of drugs to treat diseases, control symptoms, or prevent their onset is one of the most important resources for maintaining health [...].

Proton pump inhibitors and the risk of inflammatory bowel disease: population-based cohort study

OBJECTIVE

To determine whether the use of proton pump inhibitors (PPIs) compared with the use of histamine-2 receptor antagonists (H2RAs) is associated with an increased risk of inflammatory bowel disease (IBD).

DESIGN

Population-based cohort study designed to address the impact of protopathic bias.

SETTING

General practices contributing data to the UK Clinical Practice Research Datalink GOLD.

PARTICIPANTS

1 498 416 initiators of PPIs and 322 474 initiators of H2RAs from 1 January 1990 to 31 December 2018, with follow-up until 31 December 2019. Patients were analysed according to the timing of the IBD diagnosis after treatment initiation (early vs late).

MAIN OUTCOME MEASURES

Standardised morbidity ratio weighted Cox proportional hazards models were used to estimate marginal HRs and 95% CIs. In the early-event analysis, IBD diagnoses were assessed within the first 2 years of treatment initiation, an analysis subject to potential protopathic bias. In the late-event analysis, all exposures were lagged by 2 years to account for latency and minimise protopathic bias.

RESULTS

In the early-event analysis, the use of PPIs was associated with an increased risk of IBD within the first 2 years of treatment initiation, compared with H2RAs (HR 1.39, 95% CI 1.14 to 1.69). In contrast, the use of PPIs was not associated with an increased risk of IBD in the late-event analysis (HR 1.05, 95% CI 0.90 to 1.22). The results remained consistent in several sensitivity analyses.

CONCLUSIONS

Compared with H2RAs, PPIs were not associated with an increased risk of IBD, after accounting for protopathic bias.

Using an algorithm to assess the rate and trend over time of inappropriate proton pump inhibitors prescription upon hospital discharge

BACKGROUND

There is an increasing interest in inappropriate proton pump inhibitors prescription (InPPIp), as defined by the National Institute for Clinical Excellence (NICE) guidelines.

AIMS

To evaluate the rate, trend over time and factors associated with InPPIp upon discharge from internal medicine departments.

METHODS

We evaluated patients discharged from internal medicine departments with a PPI prescription in 2014 and 2017 at an academic referral center according to a developed algorithm.

RESULTS

A total of 3,982 patients were included (50.8% women, 74% ≥ 65 years). The rate of InPPIp was 44.3% (95% CI 42.8-45.9) for the entire cohort; 68.1% for subjects aged < 65 years and 36.0% for those aged ≥ 65 years (p<0.001); 43.2% in 2014 and 45.6% in 2017 (p = 0.130). In a decision-tree analysis, after the exclusion of 448 patients with gastrointestinal indications, 89.4% (1,580/1,766) of all InPPIp cases were of patients without dual antiplatelet treatment (DAPT) and 8.6% (151/1,766) were of patients younger than 65 years, who were taking aspirin.

CONCLUSIONS

The rate of InPPIp is high, especially among patients not receiving DAPT and young patients taking aspirin. Time trend analysis showed no improvement over time. Our algorithm may serve as an automated quality measuring tool to reduce InPPIp.

Clinical Intervention Increases Rational Use of Proton Pump Inhibitors in the General Surgery Department

This study aimed to evaluate the role of the clinical pharmacist in the rational use of proton pump inhibitors (PPIs) in a general surgery department. All enrolled patients had attended the general surgery department of a tertiary hospital. This single-center prospective study compared differences in the overall rate of rational PPI use, proportion of unindicated PPI use, utilization rate, average defined daily dose (DDD), drug costs, PPI costs, and cost-effectiveness of clinical pharmacist intervention between the intervention (538 cases) and control (536 cases) groups. In the intervention group, Pareto and fishbone diagram analyses were combined with the Plan-Do-Check-Act cycle; Statistical Package for the Social Sciences was used for analyzing all data. The overall rate of rational PPI use was significantly higher in the intervention group than in the control group (p < 0.01). The proportion of unindicated PPI use, utilization rate, average DDD, drug costs, and PPI costs were significantly lower in the intervention group than in the control group (p < 0.05). Cost-effectiveness analysis for the overall rate of rational PPI use indicated a positive impact of intervention, with economic benefits in the intervention group. Clinical pharmacist intervention for rational use of PPIs in general surgery departments could significantly increase the overall rate of rational PPI use; it could also reduce the proportion of unindicated PPI use, utilization rates, average DDDs, drug costs, and PPIs costs. Pharmacist intervention also offers economic benefits by improving the overall rate of rational PPI use.

Evolution of the consumption trend of proton pump inhibitors in the Lleida Health Region between 2002 and 2015

Background

Proton pump inhibitors (PPIs) are one of the most commonly prescribed pharmacological groups. Their high prevalence and duration of use are of important health concern due to the risk they can cause to patients. Despite these risks, their use remains particularly high, especially in the elderly population. We determined the trend in the prevalence of PPI consumption in the population of the Lleida Health Region between 2002 and 2015 to explore patterns of use and associated characteristics.

Methods

An analysis of secular trends between 2002 and 2015 was performed. The database included all individuals who used PPIs in the Lleida Health Region, which had 358.070 inhabitants in 2015. PPI use was evaluated using prescription dispensing data from the public health system. All types of PPIs approved by the pharmaceutical agency were included. Trends were investigated by age and sex.

Results

For the whole study period, a total of 215,417 individuals accounted for 292,122 dispensations. Overall, 48% were women, and the mean age was 62 years. The dispensing prevalence of PPI use in 2015 was 18.0% overall—20.4% for women and 15.7% for men—and was 54.6% for those over 65 years. In terms of the subtypes of PPIs, 16.8% of prescriptions were for omeprazole, 0.66% were for pantoprazole, and 0.48% were for lansoprazole. The evolution of the annual PPIs dispensation prevalence showed a progressive increase from 11.3% in 2002 to 18.0% in 2015, which was attributable to an increase in the use of omeprazole (9.0% vs. 16.8%) and, to a lesser extent, esomeprazole (0.02% vs. 0.4%).

Conclusion

An increase in the prevalence of PPI dispensation was observed over 14 years of follow-up. The prevalence of dispensation was especially high for the population older than 65 years, despite the risk of cognitive decline and falls. Comprehensive actions are required to to increase rational prescribing of PPIs, especially in high-risk populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13217-6.

Proton pump inhibitors and risk of gastric cancer: population-based cohort study

OBJECTIVE

To determine whether new users of proton pump inhibitors (PPIs) are at an increased risk of gastric cancer compared with new users of histamine-2 receptor antagonists (H2RAs).

DESIGN

Using the UK Clinical Practice Research Datalink, we conducted a population-based cohort study using a new-user active comparator design. From 1 January 1990 to 30 April 2018, we identified 973 281 new users of PPIs and 193 306 new users of H2RAs. Cox proportional hazards models were fit to estimate HRs and 95% CIs of gastric cancer, and the number needed to harm was estimated using the Kaplan-Meier method. The models were weighted using standardised mortality ratio weights using calendar time-specific propensity scores. Secondary analyses assessed duration and dose-response associations.

RESULTS

After a median follow-up of 5.0 years, the use of PPIs was associated with a 45% increased risk of gastric cancer compared with the use of H2RAs (HR 1.45, 95% CI 1.06 to 1.98). The number needed to harm was 2121 and 1191 for five and 10 years after treatment initiation, respectively. The HRs increased with cumulative duration, cumulative omeprazole equivalents and time since treatment initiation. The results were consistent across several sensitivity analyses.

CONCLUSION

The findings of this large population-based cohort study indicate that the use of PPIs is associated with an increased risk of gastric cancer compared with the use of H2RAs, although the absolute risk remains low.

Proton pump inhibitors and risk of colorectal cancer

OBJECTIVE

To determine whether proton pump inhibitors (PPIs) are associated with an increased risk of colorectal cancer, compared with histamine-2 receptor antagonists (H2RAs).

DESIGN

The United Kingdom Clinical Practice Research Datalink was used to identify initiators of PPIs and H2RA from 1990 to 2018, with follow-up until 2019. Cox proportional hazards models were fit to estimate marginal HRs and 95% CIs of colorectal cancer. The models were weighted using standardised mortality ratio weights using calendar time-specific propensity scores. Prespecified secondary analyses assessed associations with cumulative duration, cumulative dose and time since treatment initiation. The number needed to harm was calculated at five and 10 years of follow-up.

RESULTS

The cohort included 1 293 749 and 292 387 initiators of PPIs and H2RAs, respectively, followed for a median duration of 4.9 years. While the use of PPIs was not associated with an overall increased risk of colorectal cancer (HR: 1.02, 95% CI 0.92 to 1.14), HRs increased with cumulative duration of PPI use (<2 years, HR: 0.93, 95% CI 0.83 to 1.04; 2-4 years, HR: 1.45, 95% CI 1.28 to 1.60; ≥4 years, HR: 1.60, 95% CI 1.42 to 1.80). Similar patterns were observed with cumulative dose and time since treatment initiation. The number needed to harm was 5343 and 792 for five and 10 years of follow-up, respectively.

CONCLUSION

While any use of PPIs was not associated with an increased risk of colorectal cancer compared with H2RAs, prolonged use may be associated with a modest increased risk of this malignancy.

Pharmacist-structured review of proton pump inhibitor utilisation in primary care: A nonrandomised control study

INTRODUCTION

In the primary care setting, proton pump inhibitor (PPI) overutilisation often stems from the failure to discontinue prophylaxis treatment prior to tertiary care discharge and consider step-down therapy following discharge. Long-term PPI use can result in potential drug-related problems and unnecessary drug expenditure. This study aimed to evaluate the effectiveness of pharmacist-structured review in reducing inappropriate PPI prescriptions and estimate the potential cost saving.

METHODS

This non-randomised controlled study was conducted for 16 weeks at 17 government health clinics in Selangor, Malaysia. Eligible patients attending the outpatient pharmacies of intervention clinics were recruited consecutively and their consent was obtained. A structured review of PPIs was performed in which pharmacists identified patient demographics, indications and the length of PPI therapy using a PPI intervention form. Recommendations were discussed with physicians before prescription changes were made and documented. Moreover, standard management was conducted in the control clinics.

RESULTS

A total of 568 patients with prescriptions containing PPIs were sampled, with a total of 284 patients being placed into the control and intervention groups, respectively. Compared to the control group, inappropriate PPI utilisation in the intervention group significantly decreased from 79.9 to 30.4% (p<0.05). The changes to PPI prescriptions observed in the intervention group included: stop PPI therapy (30.8%), step-down therapy (22.9%), start substitution therapy (15.9%) and no change (30.4%). The physicians' acceptance rate for pharmacist intervention was 67.8%. A 66.1% reduction in monthly PPI pill count and a 72.0% reduction in monthly medication expenditure (RM44.85/patient/year) were observed.

CONCLUSION

The pharmacist-structured review was effective in increasing appropriate PPI utilisation and led to substantial cost savings.

[Proton-pump inhibitors treatment. Does your patient really need it?]

INTRODUCTION

Proton-pump inhibitors (PPI) are frequently prescribed for wide gastrointestinal disorders. The indications are well established, although a high rate of misuse has been reported.

METHODS

Observation cross-sectional study conducted a tertiary hospital. Adult patients who attended the emergency department were eligible. The appropriate indication was evaluated. Also, the prescription period, dosage and the prescribing clinician were reviewed.

RESULTS

300 patients were included. The indication was adequate in 142 patients (47.3%). The main indication was the primary prophylaxis for NSAIDs/ASA-induced enteropathy (n=95 patients, 31.7%). Polypharmacy was the main misuse indication (n=82 patients, 27.3%). The median prescription duration was 31 months (IQR 9-72), ranging from one month to 360 months. The duration was lower in those with correct indication (42.3 vs 59.6 months, P=.02). The primary care physician was the main responsible for prescription (n=165 patients, 55%), followed by gastroenterologist (n=38 patients, 12.7%) without significant differences in appropriateness by speciality.

CONCLUSIONS

Studies like this raise awareness about the PPI overuse and misuse. Deprescribing should be considered as essential to reduce iatrogenic risk and redundant health expenditure.

[Appropriateness of Proton pump inhibitor (PPI) recommendation in discharge letters of a gastroenterological department]

BACKGROUND AND STUDY AIMS

Proton pump inhibitors (PPI) are one of the most often prescribed drugs worldwide. They were thought to have a great safety profile before adverse effects in case of long-term medication were discussed recently. Undoubtedly, the use of PPI has to be based on a clear indication. In this retrospective analysis, we investigated the number of patients being discharged from a gastroenterological department with a PPI medication. We also analyzed if this recommendation was based on an established indication and if dose and duration of therapy were correct.

PATIENTS AND METHODS

1612 discharge letters from the period January 1^st to June 30^th 2011 were evaluated. Patients being discharged with a recommendation of PPI use were assigned to one of four groups: (1) PPI recommendation correct according to guidelines indication, dose and duration of treatment; (2) PPI recommendation correct according to guidelines indication, but with failing or false dose or duration of treatment; (3) PPI recommendation rational but not based on guidelines; (4) Failing indication, wrong recommendation. For a more detailed analysis the patients of group 1 to 4 were then assigned to various subgroups according to comorbidities and concomitant medication.

RESULTS

808 of 1612 discharge letters (50,1%) recommended a PPI use. Assignment to the four groups were as follows: (1) n=344 (42,6%); (2) n=115 (14,2%); (3) n=159 (19,7%); (4) n=190 (23,5%).

CONCLUSIONS

At time of discharge, PPI are frequently and partially uncritically recommended. Therefore, there is a need for a more intensive education of training interns and for a more critical review of the discharge letters by senior physicians. Even in case of optimal realization of these needs about 20% of debatable recommendations are not based on current guidelines.

Opioid use in patients with peripheral arterial disease undergoing lower extremity bypass

OBJECTIVE

Opioid use is common among patients with peripheral arterial disease (PAD), given that pain is a defining symptom. Unfortunately, long-term opioid use places patients at dramatically increased risk of overdose and death. Although surgical revascularization is extremely effective in alleviating ischemic pain related to PAD, it is unclear whether this practice results in the discontinuation of opioids after surgery. Therefore, we conducted the following study to investigate trends in opioid use before and after surgical bypass in patients with PAD, as well as the risk factors for continued opioid use after surgery.

METHODS

We conducted a retrospective analysis of patients undergoing open lower extremity bypass for claudication or rest pain between June 1, 2017, and March 31, 2021. Patients were grouped according to whether they reported preoperative opioid use at the time of surgery. The primary outcome was continued opioid use at 30-day follow-up after discharge. A multivariable logistic regression was conducted to estimate the association of continued opioid use with patient characteristics, preoperative opioid use, and receiving a postoperative opioid prescription.

RESULTS

Among 3873 patients undergoing surgery, the mean age was 65.7 (10.2) years and 2650 (68.4%) patients were male. There were 913 patients (23.6%) who used opioids preoperatively and hydrocodone was the most common preoperative opioid (583 [63.9%]). At discharge, 2506 patients (64.7%) received a postoperative opioid prescription. Postoperative opioid prescriptions were significantly more common for preoperative opioid users than opioid-naïve patients (813 [89.0%] vs 1693 [57.2%]; P < .001) and were significantly larger in size (24.3 [21.1] pills vs 19.9 [10.5] pills; P < .001). On 30-day follow-up, 522 preoperative opioid users (61.3%) and 616 opioid-naïve patients (28.4%) reported that they were still using opioids (P < .001). Continued opioid use at follow-up was associated with preoperative opioid use (adjusted odds ratio, 3.23; 95% confidence interval, 2.70-3.89) and receiving a postoperative opioid prescription (adjusted odds ratio, 10.83; 95% confidence interval, 7.96-15.06).

CONCLUSIONS

Most patients with PAD who use opioids preoperatively do not discontinue opioids after lower extremity bypass. Moreover, a significant proportion of previously opioid-naïve patients are still using opioids 1 month after surgery. In both cases, postoperative opioid prescriptions had the strongest association with continued opioid use. These findings underscore the need for improved prescribing practice and increased attentiveness to discontinuation of unnecessary medications after surgery.

Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

Proton Pump Inhibitors: Exploring Cardiovascular Complications and Prescription Protocol

Proton pump inhibitors (PPIs) are among the most extensively prescribed medications internationally for gastroesophageal reflux disease treatment and the prevention of gastrointestinal bleeding. Their efficiency, ease of availability, and low side effect profile offer several advantages over other treatment modalities. Long-term use and inappropriate prescribing habits have increased the presence of this class of drugs, prompting several studies to reassess their adverse effects. This article explored the possibility of a relationship between PPIs and cardiovascular adverse effects while highlighting the current prescription guidelines for PPIs. We further examined the need for more research into the etiology of PPI-related cardiovascular adverse effects and strategies to alleviate these risks.

Controversial link between proton pump inhibitors and anticancer agents: review of the literature

Drug-drug interactions represent a topic of great interest, not only due to the risk of unexpected adverse events but also due to the possibility of altering the effectiveness of a specific treatment. Inappropriate or concomitant use of drugs can often lead to changes in the bioavailability of various compounds, resulting in pharmacokinetic alterations. A recent example is the concomitant administration of proton pump inhibitors (PPIs) and anticancer agents. PPIs are overused beyond their classic indications, resulting in a high risk of interactions with other drugs, such as anticancer agents, both PO and intravenous. However, the real clinical impact of concomitant acid suppression therapy and anticancer therapies remains controversial and is not yet fully understood. Certainly, the gut microbiota plays a key role in regulating the response of the immune system, and PPIs can significantly alter the gut microbiome, resulting in gut dysbiosis. Indeed, while the link sometimes appears to lead to negative outcomes, as in the case of immunotherapy, oral capecitabine, or tyrosine kinase inhibitors, in other cases, it seems to enhance the effectiveness of intravenous chemotherapy. In this review, I analyse the possible drug interactions between PPIs and the main classes of anticancer drugs.

Hospital initiation of benzodiazepines and Z-drugs in older adults and discontinuation in primary care

OBJECTIVE

To examine factors associated with continuation of hospital-initiated benzodiazepine receptor agonists (BZRAs) among adults aged ≥65 years, specifically instructions on hospital discharge summaries.

METHODS

This retrospective cohort study involved anonymised electronic record data on prescribing and hospitalisations for 38,229 patients aged ≥65 from forty-four GP practices in Ireland 2011-2016. BZRA initiations were identified among patients with no BZRA prescription in the previous 12 months. Multivariate regression examined whether instructions on discharge messages for hospital-initiated BZRA prescriptions was associated with continuation after discharge in primary care and time to discontinuation.

RESULTS

In total, 418 hospital-initiated BZRAs were identified, 48.8% being to males and mean patient age was 79.0 (SD 8.3) years. Almost 60% of these discharge summarieshad some BZRA instructions (e.g. duration). Approximately 40% (n = 166) were continued in primary care. Lower age, being prescribed a Z-drug or great number of medicines were associated with higher risk of continuation. Of those continued in primary care, in 98 cases (59.6%) the BZRA was discontinued during follow-up (after a mean 184 days). Presence of instructions was associated with higher likelihood of discontinuation (hazard ratio 1.71, 95%CI 1.11-2.62).

CONCLUSIONS

Improved communication to GPs after hospital discharge may be important in avoiding long-term BZRA use.

Proton pump inhibitor use and appropriateness analysis: a snapshot from a secondary care hospital

Objectives

Proton pump inhibitors (PPIs) have become one of the most frequently prescribed drugs since their introduction 30 years ago. Effectiveness and safety profile of PPIs has led to their overutilization and has exposed patients to a number of potential risks. The objective of this study was to evaluate the use of PPIs in a secondary care hospital in the United Arab Emirates.

Methods

This prospective observational drug-utilization study was conducted in patients receiving treatment with PPIs and admitted to internal medicine wards of the study site. Electronic patient case records were reviewed and data on PPI prescribing was collected and analysed. Appropriateness of PPI use was assessed as per international guidelines.

Key findings

Out of 172 patients enrolled, 53.5% were females with median age of 57 years (34.3, 71.0). Four different PPIs were prescribed to study patients, pantoprazole (86.6%), esomeprazole (5.8%), rabeprazole (4.1%) and omeprazole (3.5%). Ninety-two (53.5%) patients were prescribed intravenous PPI, whereas 80 (46.5%) patients were given PPI in oral form. Overall, 103 (59.9%) patients had inappropriate PPI prescriptions. Of these inappropriate prescriptions, 22 patients had no clear indication for PPI use and for 16 patients; PPIs were indicated for stress ulcer prophylaxis in low-risk category. Corticosteroid use [odds ratio (OR): 4.34, 95% confidence interval (CI): 1.22–15.46; P = 0.023] was significantly associated with greater odds of inappropriate PPI use.

Conclusions

We report a high prevalence of inappropriate PPI prescribing among the hospitalized patients in our study. Inappropriate PPI prescribing is a concerning issue and collective efforts should be made to check and minimize the same.

Inappropriate Prescribing of Proton Pump Inhibitors in Outpatient Clinics

Proton pump inhibitors are the commonly prescribed drugs for acid-related disorders. However, many of those prescriptions are inappropriate in inpatient and outpatient settings according to the recommended guidelines. Many studies have been conducted in inpatient clinics, but data about the appropriateness of proton pump inhibitor prescribing in outpatient clinics are scarce. Therefore, the aim of this study was to determine inappropriate proton pump inhibitor prescribing rates among patients admitted to a tertiary hospital family medicine outpatient clinic. A total of 259 patients (median age = 59 years; 72.6% women) were enrolled into the study and 35.9% of them had no proper indications to utilize proton pump inhibitors. Inappropriate proton pump inhibitor usage rate was significantly higher in patients older than 60 years compared with their younger counterparts (62.4% vs. 37.6%; p = .001). The most frequent reason to use a proton pump inhibitor with nonapproved indications was polypharmacy (41.9%). Despite endoscopic evaluation, 41.9% of the patients received a proton pump inhibitor without an approved indication. A significant proportion of nonindicated prescriptions were a consequence of continued prescribing without re-evaluating patients in outpatient clinics. Consideration of proton pump inhibitor indications according to the guidelines in every admission may prevent inappropriate prescriptions.

[Evidence-Based Indication for Proton Pump Inhibitors - a Group Practice Perspective]

Evidence-Based Indication for Proton Pump Inhibitors - a Group Practice Perspective Abstract. Little is known about the extent of non-evidence-based proton pump inhibitor (PPI) prescriptions in the general practice setting in Switzerland. A recommendation for long-term therapy was included in the "Top 5 list" of "smarter medicine" for the outpatient internal medicine in 2014. The observational study recorded the proportion of patients without evidence-based indication for PPI in a practice with six general practitioners retrospectively over three months. Of 2225 patients analysed, 11.1 % (n = 248) took a PPI. The percentage of patients without a clear evidence-based indication was 46.8 %. Almost every second patient did not have a clear evidence-based indication for PPI. The results could be an incentive for general practitioners to reconsider the indication when prescribing PPI, also in the sense of "smarter medicine".

Trends in acid suppressant drug prescriptions in primary care in the UK: a population-based cross-sectional study

OBJECTIVE

To examine proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H2RA) prescribing patterns over a 29-year period by quantifying annual prevalence and prescribing intensity over time.

DESIGN

Population-based cross-sectional study.

SETTING

More than 700 general practices contributing data to the UK Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Within a cohort of 14 242 329 patients registered in the CPRD, 3 027 383 patients were prescribed at least one PPI or H2RA from 1 January 1990 to 31 December 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual prescription rates were estimated by dividing the number of patients prescribed a PPI or H2RA by the total CPRD population. Change in prescribing intensity (number of prescriptions per year divided by person-years of follow-up) was calculated using negative binomial regression.

RESULTS

From 1990 to 2018, 21.3% of the CPRD population was exposed to at least one acid suppressant drug. During that period, PPI prevalence increased from 0.2% to 14.2%, while H2RA prevalence remained low (range: 1.2%-3.4%). Yearly prescribing intensity to PPIs increased during the first 15 years of the study period but remained relatively constant for the remainder of the study period. In contrast, yearly prescribing intensity of H2RAs decreased from 1990 to 2009 but has begun to slightly increase over the past 5 years.

CONCLUSIONS

While PPI prevalence has been increasing over time, its prescribing intensity has recently plateaued. Notwithstanding their efficacy, PPIs are associated with a number of adverse effects not attributed to H2RAs, whose prescribing intensity has begun to increase. Thus, H2RAs remain a valuable treatment option for individuals with gastric conditions.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Effectiveness of Proton Pump Inhibitors in Idiopathic Pulmonary Fibrosis: A Population-Based Cohort Study

BACKGROUND

Gastroesophageal reflux disease is a common comorbidity in idiopathic pulmonary fibrosis (IPF) and may contribute to its progression. Anti-acid therapy, such as proton pump inhibitors (PPIs), has been considered as a potential treatment option for IPF. The evidence for this treatment comes from several observational studies affected by time-related bias.

RESEARCH QUESTION

Is use of PPIs in patients with IPF associated with a reduction in all-cause mortality, respiratory-related mortality, and respiratory-related hospitalization?

STUDY DESIGN AND METHODS

We used the UK Clinical Practice Research Datalink to identify a cohort of patients diagnosed with IPF between 2003 and 2016. The prevalent new-user cohort design was used to match patients initiating PPIs with non-users using time-conditional propensity scores, with follow-up until death or end of observation. Cox models were used to estimate hazard ratios (HR) and 95% CIs of death and of a respiratory-related hospitalization, correcting for informative censoring by inverse probability weighting.

RESULTS

There were 1,852 PPI users who were matched to 1,852 non-users identified among the cohort of patients with IPF, with a median survival of 2.8 years (mortality rate, 26.7 per 100 per year). The HR of all-cause mortality with PPI use was 1.07 (95% CI, 0.94-1.22), relative to non-use. For respiratory-related mortality, the HR was 1.10 (95% CI, 0.94-1.28) and 1.00 (95% CI, 0.86-1.16) for respiratory-related hospitalizations.

INTERPRETATION

PPI use was not associated with lower mortality or hospitalization incidence in this large study conducted among patients with IPF within a real-world setting of clinical practice and designed to avoid the time-related biases affecting previous studies. PPIs may not be as beneficial in treating IPF as suggested by some studies and conditionally recommended in treatment guidelines.

Potential proton pump inhibitor-related adverse effects

Proton pump inhibitors (PPIs) are one of the most common medications taken by patients worldwide. PPIs are used to treat acid-related disorders, including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and nonsteroidal anti-inflammatory drug/stress ulceration. For some of these diseases, long-term treatment is necessary. With such prolonged use, concern and investigation into potential adverse effects has increased. In addition, data are available regarding potential anticancer effects of PPIs, especially regarding solid tumors. The aim of this review is to assess the literature on PPIs with regard to common concerns, such as drug-drug interactions, the intestinal microbiome, dementia and central nervous system disease, and osteoporosis, as well as to highlight potential negative and positive impacts of the drug in cancer.

Appropriateness of proton pump inhibitors treatment in clinical practice: Prospective evaluation in outpatients and perspective assessment of drug optimisation

BACKGROUND

High rates of inappropriate proton pump inhibitor (PPI) prescriptions have been reported in retrospective database analyses. Assessing the appropriateness of long-term PPIs in outpatients, with a proactive approach at drug optimisation may enhance treatment adequacy.

AIMS

To describe the characteristics of outpatients who are on long-term PPIs, to assess the magnitude of inappropriate PPI prescriptions, and to evaluate the rate of drug optimisation following specialist recommendations.

METHODS

Appropriateness of long-term (>8weeks) PPI prescription was prospectively assessed in 249 consecutive patients referred to a Gastroenterology outpatient clinic. We recorded reason for prescription, dose, modality, duration of therapy, and attempts at PPI optimisation.

RESULTS

PPIs were inappropriately prescribed in 96/249 patients (38.6%). Gastro-oesophageal reflux disease (50/143, 35.0%) and prophylaxis of anti-platelet/non-steroidal anti-inflammatory drugs (5/49, 10.2%) were the most common PPI indications and those with the lowest rate of inappropriateness, while the highest rates were observed for treatment of dyspepsia (10/12, 83.3%) and anti-coagulant therapy (21/21, 100%). PPI treatment was optimised in 112 patients (45.0%).

CONCLUSIONS

PPIs are inappropriately used in about 40% of outpatients, reflecting scant attention to guidelines. A proactive approach may improve therapeutic adequacy in approximately half of patients. Educational efforts to guide PPI prescription should be further pursued.

Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia

Background

This study evaluated the impact of multifaceted NPS MedicineWise programs that targeted all general practitioners (GPs) in Australia in 2009 and 2015 with the aim of reducing unnecessary prescribing of proton pump inhibitors (PPIs) and encouraged stepping down to a lower strength PPI or to discontinue treatment. The 2015 intervention coincided with the release of Choosing Wisely Australia recommendations from the Royal Australian College of General Practitioners (RACGP).

Methods

Outcome measures included monthly dispensing rates of different strength PPIs prescribed by GPs to concessional patients in Australia. All PPIs were categorized according to the May 2019 revised classifications for standard and low strength PPIs except for esomeprazole 40 mg which was classified as a standard strength and esomeprazole 20 mg as low strength for this analysis. Time series analyses was conducted of the dispensing rates of PPI prescriptions for concessional patients between January 2006 and June 2016 using the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) databases in Australia. Participants were GPs with dispensed PPI prescriptions to concessional patients between January 2006 and June 2016.

Results

Following the 2009 NPS MedicineWise program we observed a 6.7% reduction in the expected dispensing rate of standard strength PPIs for concessional patients between April 2006 and March 2015, and an 8.6% reduction between April 2009 and June 2016 following the 2015 program launch. We observed a significant increase of 5.6% in the dispensing rate of low strength PPIs for concessional patients between April 2009 and March 2015, and no significant change in trend following the 2015 program.

Conclusions

The NPS MedicineWise programs were associated with reductions in the dispensing rate of standard strength PPIs by June 2016 and an increase in the dispensing rate of low-strength PPIs by March 2015 although this trend did not continue following the 2015 program. This suggests that GPs are stepping down patients to lower strength PPIs following the educational programs. However, lower strength PPIs are still not the majority of PPIs dispensed in Australian and regular interventions to sustain and improve PPI management by GPs may be warranted.

Omeprazole use and risk of chronic kidney disease evolution

RATIONALE, AIMS AND OBJECTIVES

In recent years, the use of proton pump inhibitors (PPI), especially omeprazole, has been associated with development of chronic kidney disease (CKD). These drugs are widely used worldwide. Although some studies have found an association between the use of PPI and the onset of acute renal failure and CKD. This study aims to analyze the association between the continuous use of omeprazole and the progression of CKD in adult and elderly individuals.

METHOD

A retrospective cohort study was conducted with patients followed up at a nephrology clinic in Brazil, in 2016 and 2017. Information about clinical and sociodemographic data, health behaviors, and medication use were collected from all patients diagnosed with CKD through consultation of medical charts and the Brazilian health information system (SIS). The participants were allocated into two groups: users and non-users of omeprazole, and the progression of CKD was then evaluated for each group. In the bivariate analysis, the Mann-Whitney U test to compare the quantitative variables between groups, and the Pearson/Fisher two-tailed chi-square test to compare the categorical variables were applied. Multivariate analysis was performed using Cox regression.

RESULTS

A total of 199 CKD patients were attended in the polyclinic, and of these, 42.7% were omeprazole users. There was a higher percentage of CKD progression in users (70.6%) compared to non-users (10.5%). The hazard ratio was 7.34 (CI: 3.94-13.71), indicating a higher risk of progression to worse stages of CKD in omeprazole users than in non-users. As for the other variables, no statistically significant difference was found between groups (p > 0.05).

CONCLUSION

An association between omeprazole use and progression of CKD stage was identified, showing a higher risk of disease evolution among omeprazole users.

Deprescribing Proton Pump Inhibitors in an Academic, Primary Care Clinic: Quality Improvement Project

GOAL

The goal of this study was to reduce the percentage of inappropriately prescribed proton pump inhibitors (PPIs) in patients aged 50 and older from 80% (baseline) to 60% within 12 months in an academic, internal medicine clinic.

BACKGROUND

The use of PPIs has increased drastically worldwide. Internal medicine clinic patients had inappropriate use of PPIs for an average of 4 to 5 years.

STUDY

A multidisciplinary quality improvement team used the Plan-Do-Study-Act Model of health care improvement and performed a root cause analysis to identify barriers to inappropriate use of PPIs. The outcome measure was the percentage of patients inappropriately prescribed PPI. Process measures were completion rates of PPI risk assessment and esophagogastroduodenoscopy. Interventions included the creation of customized electronic health record templates and education to providers and patients. Analysis was performed using monthly statistical process control charts.

RESULTS

The average rate of PPI discontinuation was 51.1% (n=92/180), which corresponds to 30.0% inappropriate PPI usage within 12 months. The mean PPI discontinuation rate in the 1-year prestudy, study and 6 months poststudy period was 2.0%, 32.0%, and 49.7%, respectively. The mean esophagogastroduodenoscopy completion rate was 49.8% from the baseline of <30%.

CONCLUSIONS

We achieved a statistically significant and sustainable reduction of inappropriate PPI use to 30% from the baseline rates of 80% and surpassed our goal within 12 months. This quality improvement was unique as no pharmacy personnel was utilized in this process. The multifaceted strategies in a safety-net internal medicine clinic resulted in successful deprescribing of PPI and can be replicated in other setting.

The inappropriate use of proton pump inhibitors during admission and after discharge: a prospective cross-sectional study

Background Proton pump inhibitors are often inappropriately prescribed during hospital admission and after discharge. The inappropriate prescription may be associated with increased and unnecessary healthcare costs. Objective To determine the prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge at Thailand's largest national tertiary referral center. Setting Medicine wards at Siriraj Hospital (Bangkok, Thailand) during September 2016 to September 2017. Method This prospective observational cross-sectional study in hospitalized patients who were prescribed, or who were already taking proton pump inhibitors. Medical records were reviewed to determine whether proton pump inhibitors were prescribed at discharge and at the 1-month follow-up. Main outcome measure Prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge, indication of inappropriate prescription. Results Two hundred and sixty-five patients (mean age: 65.8 ± 18.3 years, 50.9% men) were included. Approximately half of patients had proton pump inhibitor treatment initiated in the hospital, and the other 50.6% started treatment earlier. Among all patients, 50.6% were inappropriately prescribed proton pump inhibitors, in which 79.1% resulted from invalid indications. Fifty-two percent and 47.3% of patients who were prescribed proton pump inhibitors at discharge and at the 1-month follow-up had no indications for them. Gastrointestinal ulcer prophylaxis in low-risk patients was the most commonly observed incorrect indication. Aspirin (p = 0.030) and corticosteroids (p = 0.038) were both found to be significantly associated with the inappropriate prescription of proton pump inhibitors. The estimated cost of inappropriate use among inpatients and outpatients was $118,659 and $214,663 per year, respectively. Conclusion Proton pump inhibitors are excessively and inappropriately prescribed during hospital admission and after discharge in Thailand. The cost of this overprescribing is excessive and needs to be controlled.

The Phylogeny and Biological Function of Gastric Juice-Microbiological Consequences of Removing Gastric Acid

Gastric juice is a unique combination of hydrochloric acid (HCl), lipase, and pepsin. Acidic gastric juice is found in all vertebrates, and its main function is to inactivate microorganisms. The phylogenetic preservation of this energy-consuming and, at times, hazardous function (acid-related diseases) reflects its biological importance. Proton pump inhibitors (PPIs) are one of the most widely used drugs in the world. Due to the reduced prevalence of Helicobacter pylori infection as well as the increased use of inhibitors of gastric acid secretion, the latter has become the most important cause of gastric hypoacidity. In the present manuscript, we review the microbiological consequences of removing gastric acidity. The resulting susceptibility to infections has not been studied extensively, and focus has mainly been restricted to bacterial and parasitic agents only. The strongest evidence concerning the relationship between hypochlorhydria and predisposition to infections relates to bacterial infections affecting the gastrointestinal tract. However, several other clinical settings with increased susceptibility to infections due to inhibited gastric acidity are discussed. We also discuss the impact of hypochlorhydria on the gut microbiome.

Adverse Effects of Proton Pump Inhibitors-Evidence and Plausibility

Proton pump inhibitors (PPIs) have been increasingly used over the last decades and there are concerns about overuse and the numerous reported side-effects. It is uncertain whether associations between PPI use and potential side effects are causal. However, important evidence from experimental and mechanistic studies that could support a causal relationship may have been underestimated by epidemiologists and meta-analysists. In the current manuscript we review the combined epidemiological and mechanistic evidence of the adverse effects of PPI use.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Appropriateness of the use of proton pump inhibitors in the Emergency Department of a Spanish university hospital

BACKGROUND

the use of proton pump inhibitors (PPI) has increased substantially during the last years, possibly due to a significant proportion of prescriptions that do not follow the approved indications.

OBJECTIVE

to assess the prevalence of PPI prescription and the appropriateness of the prescription within the Emergency Department (ED) of a Spanish university hospital.

MATERIALS AND METHODS

a cross-sectional, retrospective prescription-indication drug-use study was performed, which selected 384 patients that presented to the ED over two days in January 2016.

RESULTS

of the total cohort, 23.2% were taking PPI before their hospital visit and only 20.2% had a correct indication and dosage; 2.9% of the patient cohort had an indication for PPI treatment but had not been prescribed them. A drug other than omeprazole was used in 25% of cases; 30.47% of the patients were discharged with a PPI and only 28.2% of them had the correct indication and dosage. Finally, 5.7% were not prescribed PPI even though it was warranted. PPI prescription increased with age whereas the indication for the prescription decreased. Furthermore, the use of these drugs was higher in hospitalized patients compared to discharged patients.

CONCLUSIONS

these results are in line with similar studies, which demonstrate the existence of an over-prescription of PPI. PPI prescription needs to be improved, thereby reducing drug interactions, adverse effects and unnecessary economical expenses.

Proton pump inhibitors: use and misuse in the clinical setting

INTRODUCTION

The introduction of proton pump inhibitors (PPIs) into clinical practice has greatly improved our therapeutic approach to acid-related diseases for their efficacy and safety. Areas Covered: The following evidence-based indications for PPI use are acknowledged by many scientific societies: treatment of the various forms and complications of gastroesophageal reflux disease, eradication of H. pylori infection in combination with two or more antibiotics, short- and long-term therapy of H. pylori-negative peptic ulcers, healing, and prevention of NSAID/COXIB-associated gastric ulcers, co-therapy with endoscopic procedures to control upper digestive bleeding and medical treatment of Zollinger Ellison syndrome. Expert Commentary: Despite the above well-defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and the endless expansion of the PPI market has created important problems for many regulatory authorities for two relevant features: the progressive increase of the costs of therapy and the greater potential harms for the patients. The major reasons for the misuse of PPIs are the prevention of gastro-duodenal ulcers in patients without risk factors and the stress ulcer prophylaxis in non-intensive care units, steroid therapy alone, anti-platelet or anti-coagulant treatment in patients without risk of gastric injury and the overtreatment of functional dyspepsia.

Diagnosis of Zollinger-Ellison syndrome in the era of PPIs, faulty gastrin assays, sensitive imaging and limited access to acid secretory testing

In recent years the diagnosis of Zollinger-Ellison syndrome (ZES) has become increasingly controversial with several new approaches and criteria proposed, differing from the classical biochemical criterion of inappropriate hypergastrinemia (i.e., hypergastrinemia in the presence of hyperchlorhydria) (Table 1). These changes have come about because of the difficulty and potential dangers of stopping proton pump inhibitors (PPIs) for gastric acid analysis; the recognition than many of the current assays used to assess gastrin concentrations are unreliable; the development of sensitive imaging modalities that detect neuroendocrine tumors (NETs) including an increasing number of the primary gastrinomas; the increased use of percutaneous or endoscopic ultrasound (EUS)-directed biopsies/cytology and the general lack of availability of acid secretory testing. In this article we will discuss the basis for these controversies, review the proposed changes in diagnostic approaches and make recommendations for supporting the diagnosis of ZES in the modern era.