Improper Proton Pump Inhibitor Prescriptions Criticized

Laird Harrison

May 22, 2019

SAN DIEGO — Prescriptions for proton pump inhibitors (PPIs) have skyrocketed over the past 2 decades, along with concerns about inappropriate use and adverse events.

Prescriptions for PPIs went from 1.6% of ambulatory care visits in 1998 to 7.6% in 2015, reported Patrick Meek, PharmD, from Albany College of Pharmacy and Health Sciences in New York, who presented an analysis of data from the National Center for Health Statistics here at Digestive Disease Week 2019.

However, the rate of increase slowed toward the end of that period, he added.

Residents often have a "very poor" understanding of PPIs which can lead to overprescription, said Chiemeziem Eke, MD, from the Baylor College of Medicine in Houston, who presented results of a chart review showing that 77% of PPIs were overprescribed in a primary care clinic.

Along with this increase in prescriptions have come more reports of adverse events, including osteoporotic-related fractures, Clostridium difficile infection, community-acquired pneumonia, and vitamin B12 deficiency (Ther Adv Drug Saf. 2017;8: 273-297).

Eke presented findings from an effort to reduce PPI prescriptions in an internal-medicine-resident-run primary care clinic. He and his colleagues developed an intervention that consisted of education highlighting indications for PPIs and the consequences of long-term use and question-and-answer sessions.

In addition, they provided a taper tool in the electronic medical records and a 4-week PPI taper order, along with a deprescribing algorithm, developed from evidence-based guidelines (Can Fam Physician. 2017;63:354-364).

Taper Order

The taper order called for a decrease to every other day for 2 weeks, then every 4 days for 2 weeks, and then cessation if the PPI was not prescribed for one of the following indications: Barrett's esophagus, severe esophagitis, peptic stricture from reflux esophagitis, Zollinger-Ellison syndrome, a history of a bleeding gastrointestinal ulcer, or chronic NSAID use in patients with bleeding risk factors.

The decision tree said that if symptoms were only occasional, patients could manage them with on-demand PPIs or H2 antagonists, and offered alternative treatments: on-demand antacid, as well as nonpharmacologic therapies, such as weight loss, eating meals at least 2 to 3 hours before bedtime, elevating the head of the bed, and avoiding dietary triggers.

During the study period, there was a 16% drop in PPI dispensing — from 66,261 to 55,322 — and a decline in PPI prescriptions deemed inappropriate from 77% to 52%.

And when providers were surveyed about PPI prescriptions, it was clear that the intervention led to a marked improvement in their understanding of the issue.

When Eke's team looked at inappropriate PPI prescriptions, they found that 65.0% were associated with gastroesophageal reflux disease (GERD), 8.5% with NSAID prophylaxis, and 8.1% with dyspepsia.

Going forward, the researchers plan to analyze the most common reasons for inappropriate prescriptions so they can target education for residents, Eke told Medscape Medical News. And they plan to look at the success of transitions from PPIs to H2 antagonists and test ambulatory pH impedance in patients with refractory GERD.

After the presentation, Paul Moayyedi, MB ChB, PhD, senior author of the evidence-based deprescription guidelines, asked whether patients had been surveyed to see if they were happy with the reduction in PPI prescriptions. "You didn't show that satisfaction remains," he said.

They did not survey patients, Eke explained, but he added that, in his experience, the proportion of patients with positive and negative feelings about the change was "about half and half."

During a separate presentation, Colin Howden, MD, from the University of Tennessee Health Science Center in Memphis, said he agrees that the overprescription of PPIs should be avoided, and described the intervention developed by Eke's team as "sensible and appropriate."

However, he said, reports about PPIs in the news media have raised unfounded concerns among patients.

Bad Press

Howden refuted studies that have suggested that PPIs raise the risk for dementia. And he warned that the underuse of PPIs is also a problem, especially for patients with risk factors for ulcers or upper gastrointestinal bleeding who take aspirin or NSAIDs.

"My own take on this is that PPIs are generally safe and well tolerated," he said. "Really, it's no big deal getting patients to stop using PPIs."

Howden was not the only researcher at the meeting to call for a closer look at adverse events. Researchers from Advocate Lutheran General Hospital in Chicago reported, in a separate presentation, that even adverse-event data maintained by the US Food and Drug Administration can be distorted by a spike in reports from lawyers.

In 2018, 13,754 PPI-related adverse event reports came from physicians and another 876 came from lawyers, according to that study's abstract.

Eke and Meek have disclosed no relevant financial relationships. Howden reports being a consultant for Ironwood, Otsuka, US World Meds, Pfizer Consumer Health, Vivelix, Frazier Management, ISOThrive, and RedHill Biopharma.

Digestive Disease Week (DDW) 2019: Abstract 458. Presented May 19, 2019.

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