Assessment Of Proton Pump Inhibitor (PPI) Prescription Patterns In A Tertiary Care Hospital: A Prospective Analysis (2024)

Abstract

This study aimed to characterize PPI prescribing patterns, focusing on unapproved indications, excessive dosages, treatment duration, and number of PPIs dispensed per prescription. Analyzing data from 171 patients in a tertiary care hospital over six months, it found higher PPI utilization among males (63%). Pantoprazole was the most prescribed PPI (69.2%), followed by Rabeprazole (15%), Esomeprazole (7.6%), Omeprazole (4.6%), and Lansoprazole (3%). Most PPI usage occurred in the 30-49 age group (46.1%). The study observed 59.06% of prescriptions were for unapproved indications, with excessive dosages seen in 22% of cases, notably with Pantoprazole (77%). Inappropriateness was higher in the 18-60 age group, with 40% treated longer than recommended. PPIs were frequently co-prescribed with antibiotics (66.6%), often for unapproved indications per NHS guidelines. The study highlights PPIs as commonly overused drugs, particularly among males, reflecting a need to optimize their use.

Keywords

PPIs, Utilization, NHS Guidelines

Introduction

Table 1 Demographic Details

Figure 1: PPI users

Table 2: Age, gender wise Utilization of PPI

Figure 2: Age, gender wise Utilization of PPI

Table 3: Characteristics of proton pump inhibitor (PPI) therapy

Figure3: Characteristics of PPI therapy based on gender

Figure 5: Prescribed Doses found in Patient Medical Records and interview

Table 5: Treatment Duration of PPIs

Figure 6: Treatment Duration of PPIs

7. NUMBER OF PPI DISPENSED PER PRESCRIPTION

The study analyzed the number of PPIs dispensed per prescription, categorized by age into 18-60 years and over 60 years. Among patients aged 18-60, 84.44% were prescribed a single PPI, with 21% receiving double. In patients over 60, the majority received a double dose (77.77%), with 15.5% receiving a single dose. Understanding these patterns is crucial for assessing PPI therapy intensity and identifying potential overuse or underuse, while also allowing analysis of gender and age-related differences in prescribing practices. These insights aid in optimizing PPI therapy, ensuring appropriate use, and minimizing unnecessary medication.

Table 6: Number of PPI Dispensed per prescription

Table 7: Appropriateness of PPI prescription

DISCUSSION

PPIs are among the most frequently prescribed drugs worldwide, and their overuse has been on the rise in recent years. 12]The current study provides valuable insights into the utilization patterns of PPI users. It was observed that a majority of the patients who were long-term users of PPIs belonged to the age group of 30-49 years,this observation aligns with the findings ofLiu Y et al., that majority of the patients were long term users of PPIs belonged to the age group of 18-65yrs.[1] Interestingly, the present study revealed a high prevalence of PPI utilization among male patients, particularly those in middle age. This finding contradicts the results of the study by Hoteit M et al., where utilization of PPI was observed more in Females.[9] The study found that Pantoprazole had the highest prescription rate among all PPIs, primarily prescribed to patients aged 18-60. Rabeprazole was the next most prescribed, followed by Esomeprazole, Omeprazole, and Lansoprazole. The majority of PPI prescriptions were for the 18-60 age group, with fewer prescriptions observed in the >60 age group due to a smaller percentage of participants. In the study, Pantoprazole was commonly prescribed, especially in individuals aged >65 years. A small percentage of PPI users were on prolonged therapy (over 6 months), mostly among those aged 65 years or older, consistent with Nishtala PS et al.'s study in New Zealand.[13] The study revealed that a significant majority of PPI prescriptions were inappropriate. Prescriptions for approved indications were limited, with H. pylori eradication prescriptions being a smaller portion. Prescriptions related to gastric diagnoses were moderate, resembling the findings of Jie Ying's survey in 45 Chinese hospitals.[14]Most PPI users were found to be using them excessively, with a higher proportion using them beyond recommended indications. Upon examination of the excessive utilization of Proton Pump Inhibitors (PPIs) in the study, it became evident that two key factors were responsible for this overuse: high-dosage regimens and extended durations of usage. Among those individuals who engaged in the excessive use of PPIs, a significant portion extended their treatment beyond the recommended duration, surpassing established clinical guidelines. The remaining subset of patients fell within the high-dosage therapy category, aligning closely with findings reported in a similar study conducted by Mayssaa H et al., which demonstrated that a significant proportion of the population exceeded the recommended treatment duration as stipulated by the NICE (National Institute for Health and Care Excellence) guidelines.[9] Pantoprazole exhibited the highest incidence of excessive use among all PPIs, with overutilization more common in patients with co-prescriptions compared to those prescribed for clinical diagnostics alone, consistent with previous research. Long-term, high-dose PPI regimens may lead to complications including hypomagnesemia, increased risk of osteoporotic fractures, and cardiovascular diseases. A "Step Down Therapy" approach is recommended after symptom alleviation, involving gradual reduction of both duration and dosage of PPI use through periodic reassessment.. [15] Present study, found that high-dose therapy was most frequently prescribed compared with standard and low-dose therapy (3.6 %), which was similar to the findings of the result Hendrix I et al in Australia in 2017. Study also found small portion of PPI users were using long-term, and undoubtedly, majority of them could have been brought down to withdraw from this therapy.[16] Despite numerous guidelines and extensive published reports highlighting the importance of appropriate use of PPIs and the potential disadvantages of inappropriate usage, the inappropriate prescribing of PPIs has persisted in clinical practice. For instance, Giannini et al.,[17]reported that PPIs were inappropriately prescribed for approximately high proportion of outpatients, and an even higher rate of inappropriate PPI use was observed in patients by the findings Thomas Y et al.,[18]These observations raise growing concerns regarding both the economic costs and safety implications, particularly when considering long-term usage. The study revealed PPIs were frequently co-prescribed with antibiotics prophylactically, despite minimal risk factors necessitating gastroprotective treatment. Co-prescription with corticosteroids was less common than in previous research. Notably, many patients used PPIs to prevent NSAID-related ulcers without high-risk factors, and Omeprazole was commonly prescribed with antiplatelets, potentially compromising clopidogrel's efficacy due to CYP2C19 metabolism. 19]

CONCLUSION:

The study identified widespread issues with PPI use, such as unapproved indications, excessive dosages, prolonged treatments, and inappropriate co-prescription with antibiotics, signaling significant overuse and frequent inappropriate prescriptions. To address these concerns, efforts should focus on limiting PPI treatments to appropriate indications, educating on proper usage, and regularly assessing risks and benefits to ensure rational use. Additionally, healthcare practitioners should monitor and re-evaluate PPI therapy regularly.

ACKNOWLEDGEMENTS

We are thankful to Management of Srinivas college of Pharmacy, Mangalore for providing all the necessary facilities to carry out this research work.it does not show any harmful effect on our body.

REFERENCES:

1. Liu Y, Zhu X, Li R, Zhang J, Zhang F. Proton pump inhibitor utilization and potentially inappropriate prescribing analysis: insights from a single-centred retrospective study. BMJ open. 2020;10(11)
2. Strand DS, Kim D, Peura DA. 25 Years of Proton Pump Inhibitors: A Comprehensive Review, Gut Liver. 2017; 11:27–37.
3. Haroon M, Yasin F, Gardezi SK, Adeeb F, Walker F. Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study. JRSM short reports. 2013;4(8)
4. Batuwitage BT, Kingham JGC, Morgan NE. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J. 2007; 83: 66–68.
5. Shaheen NJ, Hansen RA, Morgan DR, et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol. 2006; 101: 2128–2138.
6. Mo C, Sun G, Lu ML, Zhang L, Wang YZ, Sun X, et al., Proton pump inhibitors in prevention of low-dose aspirin-associated upper gastrointestinal injuries. World Journal of Gastroenterology: WJG. 2015;21(17):5382.
7. Eusebi LH, Rabitti S, Artesiani ML, Gelli D, Montagnani M, Zagari RM, et al. Proton pump inhibitors: risks of long?term use. Journal of gastroenterology and hepatology. 2017;32(7):1295-302.
8. WHO Model List of Essential Medicines 2011. Available from: http://www.whqlibdoc.who.int/. (Last cited on 2012 Dec 30; Last access date: 2013 Dec 31).
9. Hoteit M, Mattar E, Allaw R, Abou Rached A. Epidemiological study assessing the overuse of proton pump inhibitors in Lebanese population. Middle East Journal of Digestive Diseases. 2020;12(4):265.
10. Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therapeutic advances in gastroenterology. 2012;5(4):219-32.
11. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Canadian Family Physician. 2017;63(5):354-64
12. Kelly OB, Dillane C, Patchett SE. The inappropriate prescription of oral proton pump inhibitors in the hospital setting: a prospective cross-sectional study. Dig Dis Sci. 2015; 60:2280–6.
13. Nishtala PS, Soo L. Proton pump inhibitors utilization in older people in New Zealand from 2005 to 2013. Intern Med J. 2015; 45:624–9.
14. Ying J, Li L-C, Wu C-Y. The status of proton pump inhibitor use: a prescription survey of 45 hospitals in China. Rev Esp Enferm Dig. 2019; 111:738–43.
15. Lassalle M, Le Tri T, Bardou M. Use of proton pump inhibitors in adults in France: a nationwide drug utilization study. Eur J Clin Pharmacol. 2020; 76:449–57.
16. Hendrix I, Page AT, Korhonen MJ. Patterns of high-dose and long-term proton pump inhibitor use: a cross-sectional study in six South Australian residential aged care services. Drugs Real World Outcomes. 2019; 6:105–13.
17. Giannini EG, Crespi M, Djahandideh A. Appropriateness of proton pump inhibitors treatment in clinical practice: prospective evaluation in outpatients and perspective assessment of drug optimization. Dig Liver Dis. 2020; 52:862–8.
18. Thomas L, Culley EJ, Gladowski P. Longitudinal analysis of the costs associated with inpatient initiation and subsequent outpatient continuation of proton pump inhibitor therapy for stress ulcer prophylaxis in a large managed care organization. J Manag Care Pharm. 2010; 16:122–9.
19. U.S. Food and Drug Administartion. FDA drug safety communication: reduced effectiveness of Plavix (clopidogrel) in patients who are poor metabolizers of the drug.(Available: http://www.fda.gov/Drugs/ Drug Safety/Post market).

Reference

1. Liu Y, Zhu X, Li R, Zhang J, Zhang F. Proton pump inhibitor utilization and potentially inappropriate prescribing analysis: insights from a single-centred retrospective study. BMJ open. 2020;10(11)
2. Strand DS, Kim D, Peura DA. 25 Years of Proton Pump Inhibitors: A Comprehensive Review, Gut Liver. 2017; 11:27–37.
3. Haroon M, Yasin F, Gardezi SK, Adeeb F, Walker F. Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study. JRSM short reports. 2013;4(8)
4. Batuwitage BT, Kingham JGC, Morgan NE. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J. 2007; 83: 66–68.
5. Shaheen NJ, Hansen RA, Morgan DR, et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol. 2006; 101: 2128–2138.
6. Mo C, Sun G, Lu ML, Zhang L, Wang YZ, Sun X, et al., Proton pump inhibitors in prevention of low-dose aspirin-associated upper gastrointestinal injuries. World Journal of Gastroenterology: WJG. 2015;21(17):5382.
7. Eusebi LH, Rabitti S, Artesiani ML, Gelli D, Montagnani M, Zagari RM, et al. Proton pump inhibitors: risks of long?term use. Journal of gastroenterology and hepatology. 2017;32(7):1295-302.
8. WHO Model List of Essential Medicines 2011. Available from: http://www.whqlibdoc.who.int/. (Last cited on 2012 Dec 30; Last access date: 2013 Dec 31).
9. Hoteit M, Mattar E, Allaw R, Abou Rached A. Epidemiological study assessing the overuse of proton pump inhibitors in Lebanese population. Middle East Journal of Digestive Diseases. 2020;12(4):265.
10. Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therapeutic advances in gastroenterology. 2012;5(4):219-32.
11. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Canadian Family Physician. 2017;63(5):354-64
12. Kelly OB, Dillane C, Patchett SE. The inappropriate prescription of oral proton pump inhibitors in the hospital setting: a prospective cross-sectional study. Dig Dis Sci. 2015; 60:2280–6.
13. Nishtala PS, Soo L. Proton pump inhibitors utilization in older people in New Zealand from 2005 to 2013. Intern Med J. 2015; 45:624–9.
14. Ying J, Li L-C, Wu C-Y. The status of proton pump inhibitor use: a prescription survey of 45 hospitals in China. Rev Esp Enferm Dig. 2019; 111:738–43.
15. Lassalle M, Le Tri T, Bardou M. Use of proton pump inhibitors in adults in France: a nationwide drug utilization study. Eur J Clin Pharmacol. 2020; 76:449–57.
16. Hendrix I, Page AT, Korhonen MJ. Patterns of high-dose and long-term proton pump inhibitor use: a cross-sectional study in six South Australian residential aged care services. Drugs Real World Outcomes. 2019; 6:105–13.
17. Giannini EG, Crespi M, Djahandideh A. Appropriateness of proton pump inhibitors treatment in clinical practice: prospective evaluation in outpatients and perspective assessment of drug optimization. Dig Liver Dis. 2020; 52:862–8.
18. Thomas L, Culley EJ, Gladowski P. Longitudinal analysis of the costs associated with inpatient initiation and subsequent outpatient continuation of proton pump inhibitor therapy for stress ulcer prophylaxis in a large managed care organization. J Manag Care Pharm. 2010; 16:122–9.
19. U.S. Food and Drug Administartion. FDA drug safety communication: reduced effectiveness of Plavix (clopidogrel) in patients who are poor metabolizers of the drug.(Available: http://www.fda.gov/Drugs/ Drug Safety/Post market).

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