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  1. 1. Proton pump inhibitors: one size fits all?The introduction of Proton Pump Inhibitors (PPI) has given clinicians an effectiveand safe method of managing a variety of gastrointestinal diseases. However,since their introduction they have come to be seen as a panacea for anyone withdyspeptic symptoms. There also appears to be some confusion regarding courseduration and treatment versus maintenance dosages. In this article, Drs NabilSiddique, Loay Al-Dhahir and Kareem Jawad discuss their recent audit of PPIuse in two hospitals and a local general practice in Dagenham.The advent of the Proton Pump Inhibitor (PPI) range of drugs in the late 1980shas revolutionised the management of dyspeptic symptoms and their sequelae. Ithas radically altered the landscape of gastrointestinal disease (GI) enablingeffective medical treatment of gastro-oesophageal reflux disease (GORD), pepticulcer disease (PUD) and other conditions where effective gastric acidsuppression is necessary. Along with the recognition of Helicobacter Pyloriinfections, what was once almost guaranteed to result in surgery in the form of aruptured peptic ulcer, has now become eminently treatable medically. Since theirintroduction into the market as an effective and safe way to reduce gastric acidsecretion, the use of PPIs has rocketed. However, are they always used in thecorrect way with respect to dosages and indications?It is important that we correctly prescribe these very useful drugs for a number ofreasons including the cost to the NHS, lowering the probability of side-effects inpatients and reducing the burden of polypharmacy in those patients who could dowithout it. In a recent audit, we investigated how many patients at a busy districtgeneral hospital, a rehabilitataion/community hospital and a local generalpractice in Dagenham were on PPIs and the reasons for their prescription. Wefound that large numbers could have their proton pump dosages changed,representing a large saving to the NHS.GuidelinesThe common causes of dyspepsia can be attributed to GORD, PUD – bothH.pylori related and that caused by non-steroidal anti-inflammatory (NSAID) use,malignancies of the GI tract and those that can be classified as non-ulcerdyspepsia (NUD). The National Institute for Clinical Excellence (NICE) guidelinesrecommend that for patients with GORD, treatment dose PPIs should becommenced and once symptom control is achieved the dose can be steppeddown to a maintenance dose1. For PUD, treatment dose PPI should be used untilthe ulcer has healed whereupon the dose can be stepped down1. NICE state thatpatients with NUD should not be routinely commenced on PPIs unless the patienthas acid-related symptoms1. The issue of correct prescribing of PPIs is veryrelevant now as PPI usage is at an all time high and looks set to increase or atleast to remain at current levels. In 1998 alone the cost of PPI prescribing was£291 million and this is likely to be much higher now1. It is estimated that 38 percent of this cost is for repeat prescriptions for patients on high dose PPI for over
  2. 2. 12 months and therefore illustrates the percentage that could be possiblyamenable to successful dose reduction2. This represents a large potential savingto the NHS.PPIs are generally a very safe class of drugs; however, it is unknown what, ifany, effects they may have in the long term. It has been postulated thatprolonged acid suppression may cause bacterial overgrowth of the stomach byenteric organisms, which in turn may have a mutagenic effect on the gastricmucosa3. Prolonged PPI use has also been shown to lead to atrophic gastritis4.For both reasons of cost-efficiency and safety of patients it is important that weprescribe appropriately.MethodsSome 360 general medical in-patients at a large district general and a communityhospital were audited. The drug charts were used to indicate what patients wereon PPIs and what the dose was. The notes of these patients were then looked atto see when and why it was commenced. Notes were particularly assessed forthe results of any endoscopic procedures, H.Pylori status and the use of NSAIDsor steroids. We also looked at the use of PPIs in the general practice populationusing the methods described above substituting prescription sheets for hospitaldrug charts. We then decided how many of those that were on PPIs were on aninappropriate dose. We made the distinction of appropriate versus inappropriatebased on the NICE guidelines looking at duration of course and reason forprescribing.ResultsOf the 360 in-patients surveyed, 68 of them were on a PPI. Figure 1 shows abreakdown of which PPIs were used and at what dose. Of the patients that wereon PPIs we found that 51 per cent of them were on an inappropriate dose andthe course could either be ceased or reduced. In the community these figureswere even more stark – 75 per cent of those patients could have had their doseof PPI modified.ConclusionFrom the above figures it is apparent that the misprescribing of PPIs is moreprevalent than many would have supposed. The figures also show that thisproblem is worse in the community than in the acute hospital environment.The reasons for this are likely to be manifold. The first factor would be the lack ofclinician understanding of the indications of PPI prescribing. Many patients havedyspeptic symptoms, indeed 40 per cent of the population have dyspepticsymptoms in any one year1. It is tempting therefore that when confronted withthis vast body of patients both in the community and those who complain of
  3. 3. dyspeptic symptoms whilst being an in-patient for other reasons, to simplyprescribe a PPI. This may be a reasonable course of treatment for manypatients, however, the results above suggest that we need to be morediscriminatory in our prescribing of PPIs. The other reason for the malprescriptionof PPIs would result from inappropriate dosages. It has been stated that a sixweek course of a PPI along with H.pylori eradication therapy is sufficient to heal83 per cent of peptic ulcers5, thereafter the PPI can be discontinued or continuedat a maintenance dose should symptoms persist, however, this is not happening.Patients are being commenced on treatment dose PPI and this is not beingreviewed. In the community this is likely to be even more apparent with generalpractitioners (GPs) continuing to prescribe PPIs that may have been commencedby a hospital consultant.It is disheartening to see the scale of the problem of inappropriate prescribing ofsuch a common drug and to therefore infer the costs to the NHS on a local andnational scale. However, the issues identified above are amenable to simple andcost-effective intervention. It is the junior doctors who have daily interactions withthe patient’s drug chart and it is they who, in the vast majority of cases,commence and alter medications and their dosages. Most junior doctors aregiven prescribing advice pertaining to that hospital’s policy upon joining aparticular trust. This advice generally encompasses dosages and durations ofantibiotic courses, however this could also be a valuable time to give advice onappropriate PPI prescribing. Education of junior doctors is a simple, cost-effectiveapproach and one that is likely to be highly efficacious.The issue of dose review needs to be addressed as well. Pharmacists have agreat deal of interaction with patients’ medication sheets and are in a position tonote the dose of PPIs and the duration of treatment. They would be invaluable inthe regular assessment of drug charts and ensuring that PPIs are appropriatelyprescribed. They are also responsible for the medications that patients takehome upon discharge and this is yet another area where their input could proveuseful. GPs are often faced with patients who are on a PPI after a recent hospitalstay and are often unclear as to the indication. Clear indications on the GP letterof what medications have been commenced during a hospital stay, for whatreason and its modification in the future could resolve this confusion. GPs mayalso benefit from being updated as to the indications and prescribing patterns ofPPIs. General practises could also aid in reducing inappropriate PPI prescribingby ensuring that the repeat prescriptions are scrutinised more thoroughly beforepatients are given ongoing medications.LimitationsThis study looked at patients in two hospitals in Essex and patients of a singlegeneral practice in Dagenham. It is unclear as to whether these results could beextrapolated to a national scale and separate studies in other geographical areascould resolve this issue. In many cases it was unclear from the medical notes
  4. 4. whether the patient was continuing to have dyspeptic symptoms and thereforethe clinician felt it wise to continue high-dose PPI or whether the symptoms hadin fact been alleviated. In these cases where there was no explicit mention ofongoing dyspeptic symptoms, we assumed that the symptoms had beenalleviated. We also looked at only the medical population of an acute hospital,the surgical in-patients were not audited and this may have led to anunderestimation of both the numbers of patients on PPIs and those whosedosages could be modified.Dr Nabil Siddique is a Senior House Officer, Dr Loay Al-Dhahir is a ConsultantPhysician at St George’s Hospital, Hornchurch and Dr Kareem Jawad is aGeneral Practitioner from RainhamLinksReturn to GastroenterologyReturn to Archive Main PageReferences 1. Guidance on the use of proton pump inhibitors in the treatment of dyspepsia. Technology Appraisal Guidance No 7. National Institute for Clinical Excellence, July 2000 2. Houben MH, van de Beek D, Hensen EF et al. Helicobacter Pylori Eradication Therapy in the Netherlands. Scandinavian Journal of Gastroenterology Supplement. 1999; 230: 17– 22 3. Viani F, Siegrist HH, Pignatelli B et al. The effect of intra-gastric acidity and flora on the concentration of N-nitroso compounds in the stomach. European Journal of Gastroenterology and Hepatology 2002; 12(2):165–73 4. Kuipers EJ, Lundell L, Klinkenberg-Knol EC, et al. Atrophic gastritis and Helicobacter Pylori infection in patients with reflux oesophagitis treated with omeprazole or fundoplication. N Engl J Med 1996; 334(16); 1018–22 5. Helicobacter Pylori Infection. Clinical Evidence 2004; 11: 415–27