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Indications of proton pump inhibitors
 

Indications of proton pump inhibitors

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  • It has been estimated that between 10% and 40% of patients with gastro-oeophageal reflux disease(GORD) fail to respond symptomatically, either partially or completely, to a standard dose proton pump inhibitor. What constitutes refractory GORD remains an area of controversy.Most investigators believe that only patients with GORD who exhibit partial or lack of response to PPIs twice daily should be considered as PPI failures.Other potential underlying mechanisms, such as reduced PPI bioavailability, rapid PPI metabolism and, specifically, mutations in the 2C19 isoform of cytochrome p450, PPI resistance, and Helicobacter pylori status have all been shown to play a limited role in PPI failure. Pill-induced oesophagitis, skin diseases with oesophageal involvement, Zollinger–Ellison syndrome, and achalasia are very unusual causes for PPI failure and are rarely confused withGORD alone.
  • Pre-endoscopic administration of PPIs in patients with nonvariceal upper GI bleeding is still of controversial efficacy.The optimal dose and route of PPI administration has yet to be determined.
  • RebleedingThe reduction of 30-day rebleeding rates remained statistically significant in all predetermined subgroup analyses. That is, PPIs significantly reduced rebleeding independent of methodological quality of the trials, severity of baseline endoscopic signs of recent hemorrhage, type of control treatment (placebo or H2RA), geographic location of the trials (conducted in Asia or elsewhere), mode of PPI administration (oral or intravenous), dose of PPI (high-dose defined as at least 80 mg bolus followed by an intravenous infusion of 8 mg/h for 72 hours; low-dose defined as any lesser dose intravenous or oral), and whether or not endoscopic hemostatic treatment was given.Other outcomes:Surgical interventions were significantly less common with PPI treatment (6.1%) than with control treatment (9.3%); OR 0.61, 95% CI 0.48–0.78; NNT 34, 95% CI 20–50. Further endoscopic hemostatic treatment (after randomization) was also reduced with PPIs (5.6%) compared with control treatment (15.7%); OR 0.32, 95% CI0.20–0.51; NNT 10, 95% CI 8–17.MortalityDespite the beneficial effect of PPI treatment on the above outcomes, there was no evidence of an effect on all-cause mortality rates (OR 1.01, 95% CI 0.74–1.40). PPIs significantly reduced mortality among trials that had been conducted in Asia (OR 0.35, 95% CI 0.16–0.74; NNT 34, 95% CI 20–100), but had no verifiable effect among trials that had been conducted elsewhere (OR 1.36, 95% CI 0.94–1.96). Similarly to the outcome of rebleeding, a higher treatment effect of PPIs in Asian trials was confirmed by metaregression.There have been three other published meta-analyses of RCTs that have assessed the role of PPIs in peptic ulcer bleeding. The most consistent finding of these meta-analyses, which is also in agreement with the Cochrane meta-analysis, is that PPIs compared with H2RAs or placebo significantly reduce rebleeding rates in patients with peptic ulcer bleeding.
  • Non-selective NSAIDs: Ibuprofen/diclofenac/naproxenC2SI: Celecoxib, etoricoxibThe later introduced cyclooxygenase-2selective inhibitors (C2SI) exhibit a more favorable gastrointestinal safety profile, albeit withindividual differences. However, serious concerns about their cardiovascular toxicity have led to the market withdrawal of rofecoxib and regulatory warnings (European Medicines Agency) for the others. Following new reports that the increased cardiovascular risk may also apply to non-selective NSAID, the US Food and Drug Administrationissued ‘black box’ safety warnings for the entire NSAID drug class (July 2010).
  • Following the RAND/UCLA definition, a treatment had to be considered appropriate if the expected benefits exceeded the potential negative consequences by a sufficient margin.
  • number-needed-to-harm (NNH) is a clinically useful result:the number of patients who would need to be treated with low-dose aspirin instead of no therapy (placebo) to cause one additionalepisode of GI bleeding.No difference between 75-162.5 mg/d & 162.5-325 mg/d.
  • Diagnosis of ZES has been masked & will probably be delayed Patients with ZES will be diagnosed at more advanced stages
  • Administration in divided doses seems to be more effective than a single daily dose. Thus one study has shown that the same daily dose of omeprazole, administered in two divided doses (2 X 20mg), achieves a slightly better control of acid secretion than is obtainedwith single-dose administration (1 X 40mg).However, therapeutic compliance will be much more difficult to achieve in the case of divided dosage, and there are no comparative clinical studies that may allow conclusions as to whether the difference in control of gastric secretion is really relevant with respect to the therapeutic effect.
  • Bleeding peptic ulcer: Proton pump inhibitors have been shown to be effective in the management of upper digestive tract bleeding in patients with lesions at high risk of re-bleeding, either as the only treatment or in association with local haemostatic procedures. Although it has been demonstrated, in undeveloped countries, that even the oral route is effective (omeprazole 40mg twice daily), in our environment patients at high risk of re-bleeding are provided with a venous access; until oral intake can be resumed, the drug should be administered as a continuous infusion. In Spain, both omeprazole and pantoprazole are available for intravenous use. Both omeprazole and pantoprazoleare given as an initial 80mg bolus, followed by continuous infusion at a rate of 8 mg/h, although there is no uniform consensus as to the dose. After 72 h, and when the patient has resumed oral intake, it is probably advisable to maintain a dosage equivalent to omeprazole 40mg twice daily by mouth.
  • The effects of drugs of the same pharmacological group are mostly ‘class’ or ‘group’ effectsThus all statins would have similar clinical usefulness, & all ACE inhibitors would be equally useful in management of HTN.It is not scientifically valid to assume that this is always the case.For instance, it was necessary to withdraw cerivastatin from the market because of a greater frequency of rhabdomyolysis,which was detected only during postmarketing surveillance, & it has recently been suggested that the effect of ramipril on mortality inheart failure might be greater than that of other ACE inhibitors. Scientifically valid conclusions should be based on head-to-head comparative trials between the various drugs. However, as thedemonstration of differences may be quite expensive (long-term trials with large study populations), smaller studies are usually carried out, the clinical relevance of which is quite debatable. Even more to the point: all too often, equivalence studies are accepted as valid while being methodologically clearly inadequate.The concept of bioequivalence is important because these drugs are highly labile in an acid environment and are rapidly degraded ifreleased in the stomach. the effect of a given preparation depends, not only on the amount of the active molecule contained in the capsule or tablet, but at least as much on the quality and stability of the enteric coating protecting the active molecule.The potency of these bioequivalence studies is all too often debatable.
  • In the past two years some scientific evidences have suggested a possible negative interference of PPIs on antiplatelet effect of clopidogrel because of the competitive inhibition of the CYP 2C19 isoenzyme.

Indications of proton pump inhibitors Indications of proton pump inhibitors Presentation Transcript

  • Indications of Proton Pump Inhibitors Samir Haffar M.D. Assistant Professor of Gastroenterology Al-Mouassat University Hospital – Damascus – Syria
  • Carl Schwartz: 1910
  • Strategies used during the 20th century for counteracting action of gastric acid Inflexion occurs during the 1980s with introduction of drugs inhibiting gastric acid secretion Dı az-Rubio M. Drugs 2005 ; 65 (Suppl. 1) : 1 – 6.
  • “Potent acid inhibition” • pH > 4 1000-fold ↓ H concentration in stomach Reduced the pepsin activity • At least 16 h No clear evidence to 16 h as cut-off Used in many studies Described arbitrarily as maintaining an intragastric pH > 4 for at least 16 h out of every 24 h
  • 0 20 40 60 80 100 Maximum pepsin activity (%) 1 2 3 4 Gastric juice pH pH 4 is a critical threshold for gastric pepsin activity Adapted from Berstad 1970
  • H2RA or PPIs? No indications for H2RA in present day digestive diseases, perhaps with the exception of Gomollón1 F & Calvet X . Drugs 2005; 65 Suppl. 1: 25 – 33. • Management of occasional heartburn Possibly in association with an antacid • Exceptional patient who is allergic to all PPIs
  • PPIs are one of the most frequently prescribed classes of drug in the world because of:  High level of efficacy  Low toxicity  Reduced cost  Lack of alternative therapies
  • Sales of PPI & H2RA in USA & Italy United States Italy Corleto VD. Aliment Pharmacol Ther 2001 ; 15 : 1555 – 1561. Sales of PPI reach > 50% of entire market of gastric antisecretory drugs in both countries by 1998
  • Six available PPIs Generic name Trade name Daily dose Route Delayed release PPIs Omeprazole Losec® – Prilosec® 20 mg Oral Lanzoprazole Lanzor – Prevacid® 30 mg Oral – IV Pantoprazole Protonix® 40 mg Oral – IV Rabeprazole Aciphex® – Pariet® 20 mg Oral Esomeprazole Nexium® 40 mg Oral – IV Are all PPIs the same? Immediate release PPIs OMP Na bicarbonate Zegerid Oral
  • Intragastric pH control in patients with GERD Katz PO. Rev Gastroenterol Disord. 2003; 3(2): 59 - 69. Gain from 20% to 40% is achieved when comparing esomeprazole with other PPIs
  • Helpful facts on the use of PPIs • Take twice daily for first 2 – 3 days of therapy Steady state is not reached for a couple of days • First dose should be before breakfast • Second dose, if used, should be before dinner • Not likely to be effective when used as required Wolfe MM, Sachs G. Gastroenterology 2000; 118: S9 -S31.
  • Hierarchy of intragastric pH control • PPI once a day • PPI once a day plus H2RA • PPI bid • PPI bid + H2RA
  • Indications of potent acid inhibition  GERD: need more acid inhibition than PU  Helicobacter Pylori eradication  Peptic ulcer: gastric – duodenal – bleeding PU  Prevention & treatment of NSAID-induced lesions  Functional Dyspepsia  ↑Gastric acid : ZES - mastocytosis - retained antrum
  •  PPIs & GERD
  • Healing rates in erosive esophagitis 4 –12week of treatment Meta-analysis of > 2000 patients assessing 4 - 12week healing rates in patients with erosive esophagitis Chiba N et al. Gastroenterology. 1997; 112: 1798 - 1810.
  • Healing rates of erosive esophagitis according to LA Grade Richter et al. Am J Gastroenterol 2001; 96 : 656 – 665. P = 0.001
  • Maintenance of healing of erosive esophagitis Lauritsen K et al. Aliment Pharmacol Ther. 2002;17:333-341.
  • Underlying mechanisms for persistent heartburn despite treatment with PPIs Fass R & Sifrim D. Gut 2009 ; 58 : 295 – 309. 10 – 40 % of patients
  • Combined MII-pH of the esophagus Fass R & Sifrim D. Gut 2009 ; 58 : 295 – 309. Weakly acidic reflux Weakly alkaline reflux
  • Endoscopic images of eosinophilic esophagitis Linear furrows & adherent white exudatesConcentric rings Small calibre esophagus with stricture Mucosal laceration from diagnostic endoscopy
  •  PPIs & HP eradication
  • PPI & HP eradication • Single dose of PPIs reduces efficacy of HP eradication PPIs should be used at double the standard doses Exception of esomeprazole: 20mg bid is effective • No data available that might suggest one PPI to be preferable to another in this indication
  •  PPIs & peptic ulcers: Gastric – duodenal – bleeding
  • Medical therapy for gatric & duodenal ulcer • Removing injurious agent: NSAIDs or HP • Standard dose of PPI suffices • Double dose in some cases particularly in gastric ulcer • No comparative studies between various PPIs
  • Stage Characteristics Rebleeding I a Jet arterial bleeding 90 % Ib Oozing 50 % IIa Visible Vessel 25 – 30 % IIb Adherent clot 10 – 20% IIc Black spot in ulcer crater 7 – 10% III Clean base ulcer 3 – 5 % Forrest’s classification for PU bleeding
  • Forrest’s classification for bleeding PU III (clean base)II-b (adherent clot) II-a (visible vessel)I-b (oozing) II-c (black spot) I-a (arterial jet )
  • MA of PPI in UGI bleeding before endoscopy 4 RCTs – 1 512 patients • Excluding pts suspected of having variceal bleeding • Rebleeding OR 0.81; 95% CI (0.61–1.09) • Endoscopic tt at subsequent index endoscopy OR 0.93, 95% CI (0.53–1.64) • Surgery OR 0.96, 95% CI (0.68–1.35) • Mortality OR 1.12; 95% CI (0.72–1.73) Dorward S et al. Cochrane Database Syst Rev 2006;(4):CD005415.
  • PPI & bleeding PU * Barkun A et al. Ann Intern Med 2003 ;139 : 843 – 57. ** Leontiadis GI et al. Gastroenterol Clin N Am 2009 ; 38 : 199 – 213. *** Kaviani MJ et al. Aliment Pharmacol Ther 2003 ; 17 : 211 – 6. Controversial issues** • Dose No uniform consensus • Route Omeprazole 40 mg bid PO effective*** Consensus recommendations* • Initially 80 mg bolus • Followed by Infusion of 8 mg/hr for 72 hrs • After 72 h Equivalent to omeprazole 40 mg bid if oral intake is resumed
  • MA of PPIs in peptic ulcer bleeding 24 RCTs – 4373 patients included Leontiadis GI et al. Cochrane Database Syst Rev 2006;(1):CD002094. MortalityRebleeding – NNT 13
  •  PPIs & NSAIDs
  • Serious GI Events Clinical Ulcers Endoscopic Ulcers Relative Severity GI Symptoms Relative Frequency NSAID-related GI side effects
  • Choice between various NSAIDs dominated by uneasy application of ‘least harm principle’ balancing various potential adverse events
  • Risk factors for GI complications in NSAIDs users Ranked in terms of importance • Prior history of complicated ulcers • Concomitant use of anticoagulants • Multiple NSAID use, including low-dose aspirin • Prior history of uncomplicated ulcer • High NSAID dose (or use of piroxicam or ketorolac) • Age > 60 years • Severe illness • Helicobacter pylori infection • Concomitant use of corticosteroids
  • Prevention strategies of GI risk due to NSAIDs • Best way: avoid NSAID & substitute with acetaminophen • Use “safer” NSAID: C2SI, diclofenac, aceclofenac, ibuprofen • Avoid of NSAID with highest GI toxicity Ketorolac, piroxicam, ketoprofen • Use lowest effective dose for shortest period of time • Avoid concomitant therapy with Anticoagulants, corticosteroids, low-dose aspirin, APT • Eradicate HP infection in patients with prior ulcer history Sostres C et al Best Pract Res Clin Gastroenterology 2010 ; 24 : 121 – 132.
  • Patients at increased risk for NSAIDs GI toxicity High risk 1. History of complicated ulcer especially recent 2. Multiple (> 2 risk factors) HP is independent & additive risk factor & addressed separately ACG guidelines for prevention of NSAID-related ulcer complications . Am J Gastroenterol 2009 ; 104: 728 – 738. Moderate risk (1 – 2 risk factors) 1. Age > 65 years (OR 2.0 – 3.5) 2. High dose NSAID therapy (OR 8.0) 3. Previous history of uncomplicated ulcer 4. Concurrent use of aspirin 5. Concurrent use of corticosteroids (OR 2.0) 6. Concurrent use of anticoagulants (OR 3.0) Low risk No risk factors
  • Patients at increased risk for NSAIDs CV toxicity High risk Patients with risk factors for CV disease often receive prophylactic aspirin Arbitrarily defined as requirement for low-dose aspirin for prevention of serious CV events Low risk No risk factors
  • Prevention of NSAID-related ulcer complications Low GI risk Moderate GI risk High GI risk Low CV risk NSAID alone (least ulcerogenic at lowest dose) NSAID + PPI/misoprostol Alternative therapy or C2SI + PPI/misoprostol Patients with ulcer history: search for HP & if present eradicated Naproxen may have some cardioprotective properties ACG guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol 2009 ; 104: 728 – 738. High CV risk Naproxen + PPI/misoprostol Naproxen + PPI/misoprostol Avoid NSAIDs & C2SI Use alternative therapy
  • GI safety of non-selective NSAIDs RR of different NSAIDs could differ 10-fold * Risk at higher doses (> 1.5 –2.4 g/d) comparable to others NSAIDs Br Med J 1996 ; 312 : 1563 – 1566. Lowest risk Ibuprofen * Diclofenac Moderate risk Indomethacin Naproxen Sulindac Aspirin Highest risk Azapropazone Tolmetin Ketoprofen Piroxicam Longer half-time
  • SENSAR software Appropriate use of NSAIDs in chronic rheumatic disease • 18 experts from 10 European countries • Published English-language literature from 1998 to 2008 • Method: Research & Development/UCLA(RAND/UCLA) • Three panel meeting: January, June, &November 2008 • 144 different patient profiles & 10 treatment options • Statement: Appropriate – Uncertain – Inappropriate • Coordinated by Center for Decision Analysis & Support • Supported by Pfizer Inc http://www.e-hims.com/Sensar/
  • European expert panel on appropriate use of NSAID Name Speciality Country 1- Gerd R Burmester Rheumatology Germany 2-Francis Berenbaum Rheumatology France 3- Ferdinand Breedveld Rheumatology The Netherlands 4- Maxime Dougados Rheumatology France 5- Emilio Martín Mola Rheumatology Spain 6- Ignazio Olivieri Rheumatology Italy 7- Josef Smolen Rheumatology Austria 8- Stefan Lohmander Orthopaedics Sweden 9- Luigi M Biasucci Cardiology Italy 10- Matthias Hermann Cardiology Switzerland 11- Tom MacDonald Cardiology and Clinical Pharmacology UK 12- Chris Hawkey Gastroenterology UK 13- Angel Lanas Gastroenterology Spain 14- Carmelo Scarpignato Gastroenterology and Clinical Pharmacology Italy 15- Adam Bajkowski Family Medicine UK 16- Peter Dieleman Family Medicine Belgium 17- Tony Mets Geriatrics Belgium 18- Nele Van Den Noortgate Geriatrics Belgium
  • http://www.e-hims.com/Sensar/
  • SENSAR software Appropriate use of NSAIDs in chronic rheumatic disease • Given complexity of data & to avoid oversimplification: Electronic tool may offer best opportunities as quick reference guide to panel results • In the complex and dynamic area of NSAID use: Such approach offer best chances of benefiting from perspective of both science & practice http://www.e-hims.com/Sensar/ Burmester G et al. Ann Rheum Dis 2011 ; 70 : 818 – 822.
  • Major GI bleeding in low dose aspirin 14 RCTs – over 57 000 patients McQuaid KR et all. Am J Med 2006 ; 119 : 624 – 638. Major GI bleeding: fatal – hospitalization – transfusion Low dose asipirin: 75 – 325 mg/day NNH during 1 year period: 833
  •  PPIs & dyspepsia
  • Functional dyspepsia • Persistent or recurrent pain or discomfort centered in the upper abdomen for more than 12 weeks in the preceding 12 months with no evidence of an organic disease that is likely to explain the symptoms • Divided into 4 symptom groups: Ulcer-like Reflux-like Dysmotility-like Unspecified
  • Alarm features in dyspepsia (red flags) • Age > 55 years with new-onset dyspepsia • Family history of UGI cancer • Unintended weight loss • Gastrointestinal bleeding • Progressive dysphagia or odynophagia • Unexplained iron-deficiency anemia • Persistent vomiting • Palpable mass or lymphadenopathy • Jaundice AGA technical review on evaluation of dyspepsia. Gastroenterology 2005 ; 129 : 1756 – 80. 
  • PPI versus placebo in uninvestigated dyspepsia MA of 4 RCTs AGA technical review on evaluation of dyspepsia. Gastroenterology 2005 ; 129 : 1756 - 80.
  • PPI versus placebo in nonulcer dyspepsia MA of 8 RCTs AGA technical review on evaluation of dyspepsia. Gastroenterology 2005 ; 129 : 1756 - 80.
  •  PPIs & Zollinger-Ellison syndrome
  • Suspicion of ZES • Refractory erosive esophagitis • Multiple peptic ulcers • Ulcers in distal duodenum or jejunum • Complicated ulcers • Recurrent ulcers after acid-reducing surgery • Ulcers associated with diarrhea • Family history of MEN-1
  • Diagnosis of ZES
  • Treatment of ZES • Surgery Gastrinoma enucleation Parietal cell vagotomy Total gastrectomy (abandoned) • PPI Control acid secretion in most patients Very high doses (eg, omeprazole 120mg/day) BAO < 10 mEq/h 1 hour before next dose < 5 mEq/h in prior gastric surgery Schubert ML & Peura D A. Gastroenterology 2008 ; 134 : 1842 – 1860.
  • Referrals & diagnosis of new cases of ZES in 2 centers after widespread use of PPIs Corleto VD. Aliment Pharmacol Ther 2001 ; 15 : 1555 – 1561.
  • Retained antrum syndrome Hauser SC et al. Mayo clinic gastroenterology & hepatology board review. Mayo Clinic Scientific Press, Rochester, USA, 3rd edition, 2008. Retained antral tissue with gastrin secreting cells
  • What dose of PPIs? Generic name Standard dose (mg/day) Refractory patient (mg/day) Omeprazole 20 mg 80 mg Lanzoprazole 30 mg 120 mg Pantoprazole 40mg 160 mg Rabeprazole 20 mg 80 mg Esomeprazole* 40 mg 80 mg * Therapeutic advantage of esomeprazole, which is less relevant in overall population, might be of more interest in refractory one
  • When Should the PPI be Given? 15 – 30 minutes before meal Before morning meal Reduces acid secretion more than given in the evening Does not affect nocturnal acid secretion Before mid-day meal More effective inhibition of nocturnal secretion If single daily-dose Before breakfast or mid-day meals If no response Divided doses: compliance problem Increased dose (more reasonable) Gomollo n F et al. Drugs 2005; 65 (Suppl 1) : 25 – 33.
  • PPI dose adjustment • Renal failure No repercussion on PPI elimination No need to adjust dosage • Liver failure Half-life increases to 4 – 8 h (nl: 1 h) Reduction of dosage • Aged patients No dosage adjustment usually Adjustment if hepatic or renal failure is added to advanced age Drugs 2005; 65 Suppl. 1
  • For how long? Indication Duration GERD Indefinite period of time or use on demand HP eradication 7 – 10 – 14 days Duodenal ulcer 4 wks – duration increased in refractory cases Gastric ulcer 8 wks – duration increased in refractory cases Bleeding PU IV PPIs for 72 hours (consensus) Gastroprotection As long as patient requires NSAIDs or ASA Dyspepsia Depend on symptomatic response ZES Indefinite period of time
  • Which PPIs?  Efficacy Esomeprazole (40mg/d) slightly more effective Useful in refractory ulcer Useful in difficult GERD: extent of lesion – Barrett’s  Interactions with other drugs Less interaction in rabeprazole & especially pantoprazole Clinical relevance probably minimal Dose adjustment in AVK, benzodiazepines, phenytoin  Cost considerations
  • Major metabolic pathways for various PPIs De Argila CM. Drugs 2005; 65 (Suppl. 1) : 97 – 104. Contribution of each isoenzyme represented by thickness of arrow Rabeprazole: Important non-enzymatic metabolism Pantoprazole sulfotransferase not saturable
  • PPI & clopidogrel co-therapy  Evaluate risk of PU & GI bleeding in dual APT  Administer PPI in patients at high risk Administer PPI in all patients with dyspepsia  Prefer pantoprazole or rabeprazole Weak inhibitors of CYP2C19 Pantoprazole considered the first choice PPI  Separate administration by 12 – 15 hours Half life of PPI 1 – 2 h & clopidogrel 4 – 6 h PPI before breakfast & clopidogrel after dinner Lettino M. Eur J Intern Med 2010 (in press).
  • Mechanisms of suboptimal PPIs response • Variable bioavailability of PPIs • PPIs taken at times other than just before a meal • Hypersecretors: uncommon • Genetic variations in CYP 450 2C19 enzyme: rapid metabolism • Eradication of H pylori: controversial • PPI resistance despite normal blood levels of drug Strongly suggesting genetic abnormality of proton pump Ramakrishnan A. et al. Gastrointest Endoscopy Clin N Am 2003; 13 : 57 – 68.
  • Overprescribing PPIs In a series of hospital inpatients in Michigan, USA • On admission 20% of patients taking PPI • During hospital stay Another 40% were prescribed PPI Mostly for prophylaxis • At discharge 50% of patients taking PPIs 90% of patients did not need PPIs unless having GERD in the past Ann Pharmacother 2006 ; 40 : 1261 – 6. PPIs are clearly being overused
  • Overprescribing PPIs • 2006 Expenditure on PPIs in England £425m Expenditure on PPIs in the world £7bn • 25-70% of pts taking PPIs have no appropriate indication • Money spent unnecessarily on PPIs each year England at least £100m Worldwide at least £2bn Bruzzi P. BMJ 2008 ; 336 : 2 – 3.
  • Conclusion The lowest effective dose of the cheapest drug for the shortest possible time Prescribing PPIs
  • Thank You