Abstract

Purpose: PPI's (Proton Pump Inhibitors) are the most commonly prescribed class of medications throughout the world. In 2008, Nexium (esomeprazole) was third on the top 15 global pharmacological products with sales of $7842 million globally. The main indications for the prescription of PPI's include GERD, peptic ulcer disease and non-ulcer dyspepsia. They are considered relatively safe with fewer effects. Several studies have highlighted the unwarranted effects of PPI and certainly these drugs should only be used if there is a true indication. The recent NICE (UK) Guidelines from 2005 recommends their use should be limited to the lowest possible maintenance dose, to be offered to control the symptoms with minimum number of repeat prescriptions or switching to on demans PPI's. Methods: We did a prospective patient centered survey of randomly selected inpatients on medical wards. Only those patients were included who were on PPI prior to the admission. The patients admitted with upper GI bleed, on high dose steroids and the ones with cognitive impairment were excluded. A proforma including patient's age, sex, medications, comorbidities and a set of six questions was formulated and patient's responses documented. Results: 45 medical inpatients were selected of which 24% were male and 76% female. Most of them (73%) were aged between 30-85 with only 7% <29 yr AND 20% >85 yrs old. 30% of those surveyed were not sure how long they were on PPI's and 22% were on these for more than 8 years. Coming to the questionnaire, 70% of the patients knew why they were on PPI's with 18% on them due to hiatus hernia, 54% due to heartburn and 28% were not sure why they were on them. 41% had previous gastroscopy and a minority (4%) had a diagnosis of gastric ulcer in the past. Steroids were never used by 73% of those surveyed. The important thing to note was that 83% of those surveyed were not tried on any other anti-dyspeptics prior to starting PPI. Conclusion: In conclusion, our survey has shown that most of the patients on PPI were never tried on any other anti-dyspeptics previously and have been left ON PPI's long term with no periodic review. A recent study published in JAMA indicated increased risk of death or rehospitalization in patients on clopidogrel plus PPI compared with use of clopidogrel alone. Other studies have shown an increased risk of hip fractures, increase in the odds of hospital acquired pneumonia by 30%, increase in the risk of Clostridium difficile infection and hypomagnesemia in patients on long term PPI's. In view of the above evidence, we recommend that the physicians should be more proactive in regularly reviewing patients' medications including PPI's in order to avoid the unwanted adverse effects of the drug, polypharmacy and to cut the cost of health care provision.

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