Capsule Commentary on Gawron et al., Proton Pump Inhibitor Prescriptions and Subsequent Use in US Veterans Diagnosed with Gastroesophageal Reflux Disease

Abstract

In this single-center study conducted at the Hines, IL, VA Hospital, Gawron et al.1 examined characteristics of initial and subsequent proton-pump inhibitor (PPI) prescribing in veterans within 30 days of an ICD-9 code for gastroesophageal reflux disease in the outpatient setting. They found that of these initial PPI prescriptions, 23.3 % were high dose, and the majority were for 90 days or more. Only 11.9 % of patients receiving an initial high-dose prescription and 3.3 % of patients overall had evidence of step-down therapy. Additionally, 83.8 % of patients received at least one refill, with a high medication possession ratio over 2 years. Taken together, these data suggest that few patients are receiving or successfully completing a trial of step-down or discontinuation of therapy. Unfortunately, because prescription data do not necessarily reflect the communication between physician and patient, we are unable to know whether the low rate of step-down or discontinuation of therapy represents a failure of physicians to recommend such a trial or a failure of patients to tolerate it. However, the findings of Inadomi et al.2 that many, if not most, patients can tolerate step-down therapy suggest that the former is more likely. Furthermore, the high medication possession ratio in this study suggests that continuous rather than on-demand use is predominant. These results draw attention to the main problem plaguing this highly effective class of medications: once patients are on PPIs, they tend to stay on them. While the reasons for this are manifold, research suggests that many of these prescriptions are unnecessary, and physicians all too often fail to assess the necessity of continued use.3,4 This study highlights the great need for the development of strategies to prompt periodic re-evaluation of the need for all medications on a patient’s medication list. The same sophisticated computerized system that makes ordering and refilling prescriptions at the VA so easy could also provide a solution, in the form of computerized clinical decision support. The most efficient and effective means of such comprehensive medication management—for PPIs and beyond—is not yet clear and will be an important focus of future studies.