The inappropriate use of proton pump inhibitors and its associated factors among community-dwelling older adults

BackgroundA large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients.MethodsWe searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use.ResultsWe included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies.DiscussionAll identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.

Purpose: We previously reported proton pump inhibitor (PPI) overuse in hospital patients, especially for stress ulcer prophylaxis (SUP). To evaluate the effectiveness of education, we examined the indication and frequency of PPI use in hospitalized patients again after intervention. Methods: We prospectively analyzed pharmacy orders of all adult patients admitted to the hospital who received a PPI in two separate phases. Phase 1 (P1) was for 45 days in 2005 and phase 2 (P2), after the intervention, was for 45 days in 2008. Indication for PPI use, hospital prescribing service and discharge PPI use were determined. Between P1 and P2, didactic conferences were conducted for the Internal Medicine (IM) residents on appropriate PPI prescribing and the IM admission template was updated to exclude routine SUP. Appropriate indications for PPI use included: maintenance of healed duodenal ulcers, H. pylori eradication, GERD, upper GI hemorrhage, maintenance/healing of erosive esophagitis, prevention/healing of NSAID-induced ulcers, relief from dyspepsia, SUP in high risk ICU patients, and continuation of home PPI. A two-proportion z- test was used to compare percentage of PPI use between the two phases. Results: Twenty-six percent (n=463) of adult patients admitted in P1 were prescribed a PPI and 36% (n=688) of patients in P2. Patients received a PPI for: SUP, GERD, not documented, GI bleed, continuation of home medication, peptic ulcer disease, esophagitis, and other. Inappropriate PPI administration decreased from 64% in P1 to 52% in P2 (p<0.0001). Inappropriate PPI use for SUP decreased from 86% to 76% (p<0.003). Importantly, in the intervention group, inappropriate use for SUP decreased from 62% to 41% (p<0.0001). Also, while 55% of patients in P1 were discharged on a PPI without appropriate indication, this decreased to 17% after the intervention in P2 (p<0.0001). Patients discharged on a PPI after being prescribed one for SUP decreased from 36% in P1 to 18% in P2 (p<0.0001). Although there was an overall increase in PPIs prescribed for inpatients in P2, a significant decrease was seen in PPIs prescribed for inappropriate reasons. Conclusion: Caution must be used when initiating PPI therapy in the hospital setting. Long-term therapy often continues unnecessarily at discharge leading to increased healthcare costs, polypharmacy, and increased risk for potential adverse effects. In conclusion, this study indicates that intervention through physician education can lead to a significant decrease in inappropriate inpatient PPI use.

Several hospital-based studies have determined that physicians often inappropriately prescribe acid-suppressive medications for stress ulcer prevention in hospitalized patients and continue these drugs after discharge. We sought to determine the frequency of inappropriate proton pump inhibitor (PPI) use continued at discharge within our geographic region. We undertook a retrospective review of the medical records and pharmacy prescription database of a large regional insurance carrier from January 2005 through December 2008 (total hospital admissions 96,669). The primary inclusion criterion was hospital-initiated PPI therapy and continuation on hospital discharge without an appropriate indication. Patients receiving a PPI at the time of admission were excluded from the analysis. The number of patients per year discharged on a PPI decreased during the study period: 876 (2005), 763 (2006), 562 (2007), and 485 (2008). Of the patients discharged on a PPI, the number (%) of patients receiving PPIs inappropriately were 695 (79%; 2005); 627 (82%; 2006), 441 (78%; 2007), and 397 (82%; 2008). The annual number of PPI prescriptions and PPI doses dispensed decreased from 2015 to 1263 and from 60,608 to 38,742, respectively, during the study period. The estimated 4-year cost of inappropriate PPI use was $595,809, although cost savings from the absolute reduction in inappropriate PPI use over time was $65,598. We report a significant decrease of 39% in the number of inappropriate discharge prescriptions for PPIs during the study period; however, the percentage of inappropriate use of PPIs remains high. There is room for improvement in cost-effective use of PPIs.

The potentially inappropriate use of the proton pump inhibitors is prevalent in older adults. To evaluate the impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients. This parallel nonrandomized controlled study was conducted at an internal medicine service of a tertiary training and research hospital between September 2019 and August 2021. Older patients (≥ 65 years old and received proton pump inhibitors within 48h of admission) were allocated to two groups according to their number of medical file records, whether odd or even, two groups: control and clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy (including medication reconciliation and medication review) during the hospital stay. Primary outcome measures were the rate of appropriate use of proton pump inhibitors during hospitalization and potentially inappropriate proton pump inhibitor use at discharge. The rate of appropriate proton pump inhibitor use during hospitalization was significantly higher in the clinical pharmacist-led program (n = 100) than in the control group (n = 97) (46.4% vs. 79.0%; P < 0.001). The rate of potentially inappropriate proton pump inhibitor use at discharge was significantly lower (61.7% vs. 35.1%; P < 0.05) in the clinical pharmacist-led program among the older patients discharged with a proton pump inhibitor prescription. A clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy improved the rate of appropriate proton pump inhibitor use and reduced the potentially inappropriate proton pump inhibitor use during the hospital stay. NCT05113667 (17 October 2021-registered retrospectively).

BackgroundIn accordance with current guidelines, proton pump inhibitors (PPIs) are now generally prescribed as a protective co-medication in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose acetylsalicylic acid (LDASA). However, less attention is paid to the corresponding discontinuation of a PPI after cessation of NSAID or LDASA treatment.ObjectiveThe aim of this study was to assess the extent of inappropriate PPI use, as the proportion of patients who started a PPI as a protective co-medication but continued using these drugs after cessation of NSAID and LDASA treatment. We also sought to estimate the potential cost savings and effect gains of discontinuing inappropriate PPI use and the resulting decrease in adverse effects and their detrimental consequences.MethodsPharmacy dispensing data were used to map inappropriate PPI use in 2014 for community-dwelling patients. Strategies with or without PPI continuation were compared in the cost–utility analysis for a time horizon of 5 years from a healthcare perspective. Subsequently, incremental costs and effects (quality-adjusted life-years) were estimated with a Markov model.ResultsRelated to NSAID and LDASA treatment, 11.0% and 5%, respectively, of the PPI users were found to inappropriately continue PPI co-treatment. Discontinuation in 71- to 80-year-old patients suggested cost savings of €170.46 (95% confidence interval 75–282) at a 0.003 (95% confidence interval 0.001–0.005) quality-adjusted life-year increase. The total budget impact of stopping inappropriate PPI use related to NSAID/LDASA treatment in the Netherlands would amount to almost €1,050,000 after 1 year. Correspondingly, successful interventions to stop a patient’s inappropriate use would cost up to €29 and probably would pay for themselves in the following years.ConclusionsA substantial number of patients inappropriately continue to use a PPI after cessation of NSAID or LDASA treatment. Because adverse effects and their detrimental consequences are avoided, interventions to stop inappropriate PPI use, particularly in older patients, are likely to pay for themselves.Electronic supplementary materialThe online version of this article (10.1007/s40266-019-00713-5) contains supplementary material, which is available to authorized users.

Proactive Measures Aimed at Improving Appropriateness of Use of Proton Pump Inhibitors in Clinical Practice

Proton pump inhibitors (PPIs) are commonly used and often prescribed inappropriately, which increases the risk of adverse events. Deprescribing is a health professional-supervised intervention aimed at reducing or discontinuing medications that may cause harm or no longer provide benefits. To evaluate the effectiveness of a collaborative intervention involving community pharmacists and general practitioners in deprescribing inappropriate PPIs (ATC/WHO A02BC) among community-dwelling older adults (aged ≥ 65 years). This was a pragmatic, multicentre, non-randomised two-arm-controlled trial with 6-month follow-up in Portuguese primary care, involving community pharmacies and family health units (FHUs) to deprescribe long-term PPIs (> 8 weeks). The intervention comprised a pharmacy-based patient awareness and education approach, followed by a clinical assessment by general practitioners to assess inappropriate use and initiate the deprescribing process, along with pharmacy-based follow-up to monitor the withdrawal process. The comparator was usual care. The primary outcome was successful deprescribing, defined as the discontinuation or dose reduction of any PPI at 3 and 6 months. Secondary measurements included clinical and drug-specific outcomes. An intention-to-treat analysis was performed. The study included 166 patients (mean age 74.2 years (SD 6.0 years), 59.0% female) who had been using PPIs for an average of 10.6 years (SD 7.3 years). The intervention was found to be effective in reducing PPIs use. At 3 months, the adjusted absolute risk difference in deprescribing between the intervention group (IG) and the control group (CG) was 46.3% (95% confidence interval (CI) 32.8-59.9, number needed to treat of 2.2). The relative risk of deprescribing in the IG compared with the CG was 9.6 (95% CI 3.6-25.6). At the 6-month follow-up, the effect remained similar. No significant differences between the IG and CG were observed for secondary outcomes. This collaborative deprescribing intervention has been effective in reducing inappropriate PPI use, highlighting the need for ongoing multidisciplinary efforts and supportive policies to optimise medication use in older adults. Larger trials with longer follow-ups are necessary for a better assessment of various patient-reported outcomes and the long-term impact of these deprescribing interventions. ISRCTN49637686, 14/06/2023 "retrospectively registered".

BackgroundMisuse of proton pump inhibitors (PPIs) is an alarming issue for patients and healthcare systems.MethodsWe conducted a 3-phase interventional, prospective study in a Greek university hospital. During Phase I, we collected data from patients’ records to evaluate the appropriate use of PPIs. During Phase II, educational seminars about the proper use of PPIs were offered to the medical staff. In Phase III we collected data from the records of patients admitted to the hospital department with the highest rate of inappropriate PPI administration during Phase I, to evaluate the efficacy of the intervention. Inappropriate use was defined as either PPI administration without indication, or lack of use despite adequate indication. Appropriateness of PPI use was measured at admission, during hospitalization and at discharge.ResultsThe rate of inappropriate PPI use was higher (51.7% and 48.6%) during hospitalization than at admission (34.9% and 21.9%), but at discharge was similar to pre-hospitalization levels (26.9% and 23.6%), in Phases I and III, respectively. At discharge during Phase I, the inappropriate use of PPIs was significantly higher (odds ratio 3.79, 95% confidence interval 1.98-7.19) for internal medicine patients than for surgical patients. The educational intervention failed to reduce the inappropriate use of PPIs during hospitalization (51.7% vs. 48.6%, P=0.478) or at discharge (26.9% vs. 23.6%, P=0.391) in the internal medicine patients.ConclusionsThe rate of inappropriate PPI use is almost double during hospitalization compared to the rates at admission and at discharge. Implementation of an educational intervention failed to reduce the inappropriate use of PPIs in internal medicine patients.

Background: Proton pump inhibitors (PPIs) are among the most widely prescribed class of medications in the United States. Although effective in the treatment of acid related disease, inappropriate PPI use is prevalent, and long-term PPI use has been associated with adverse effects. Objectives: This evaluation explores the novelty of a student-pharmacist directed PPI deprescribing telehealth program with the goals of (1) determining whether PPIs are appropriately prescribed in Veterans via remote student-led chart reviews, (2) identifying if a gap exists between urban and rural Veterans prescribed a PPI, and (3) assessing the feasibility of integrating student pharmacists into the PPI deprescribing process utilizing telehealth visits through a pilot study. Methods: Student pharmacists evaluated PPI appropriateness in Veterans at the William S. Middleton Veterans Hospital. Students collected data via remote chart reviews, compared appropriateness of PPI therapy in rural versus urban Veterans, and conducted a deprescribing pilot call study in rural Veterans with inappropriate PPI indications. Clinical decision-making was agreed upon in collaboration with pharmacist preceptors, however all means of communication with Veterans was performed by student pharmacists. Results: 51% of Veterans were found to have an inappropriate indication for their PPI, though comparison of inappropriate PPI use in rural versus urban Veterans was not statistically significant (n=170, p-value 0.34). 83% of Veterans agreed to proceed with PPI deprescribing and 71% of Veterans ended the pilot study with at least some degree of PPI dose reduction (n=33). Conclusion: Inappropriate PPI use among rural and urban Veterans is prevalent, however a significant difference was not observed between the two cohorts. Student pharmacists are capable of successful telehealth deprescribing interventions in collaboration with pharmacists.

BackgroundThe prevalence and characteristics of inappropriate use of proton pump inhibitors (PPIs) to prevent stress-related mucosal disease (SRMD) during the perioperative period and its associated factors are rarely reported. This study aimed to investigate the prevalence and characteristics of inappropriate prophylactic use of proton pump inhibitors (PPIs) during the perioperative period and identify its associated factors in a tertiary care and academic teaching hospital in China and to provide evidence for regulation authorities and pharmacists to take targeted measures to promote rational drug use.MethodsInpatients who underwent surgical operations and received prophylactic use of PPIs from June 2022 to November 2022 were included in this retrospective study. The appropriateness of perioperative prophylactic use of PPIs was evaluated by clinical pharmacists. Associated factors with inappropriate perioperative prophylactic use of PPIs were analyzed by univariable and multivariable logistic regression.ResultsFour-hundred seventy-two patients were finally included in this study, of which 131 (27.75%) patients had at least one problem with inappropriate perioperative prophylactic use of PPIs. The three most common problems were drug use without indication (52.0%), inappropriate usage and dosage (34.6%), and inappropriate duration of medication (6.7%). Multiple logistic regression analysis showed that oral dosage form of PPIs [OR = 18.301, 95% CI (7.497, 44.671), p < 0.001], discharge medication of PPIs [OR = 11.739, 95% CI (1.289, 106.886), p = 0.029], and junior doctors [OR = 9.167, 95% CI (3.459, 24.299), p < 0.001] were associated with more inappropriate prophylactic use of PPIs. Antithrombotics [OR = 0.313, 95% CI (0.136, 0.721), p = 0.006] and prolonged postoperative hospital stay (longer than 15 days) [OR = 0.262, 95% CI (0.072, 0.951), p = 0.042] were associated with less inappropriate prophylactic use of PPIs.ConclusionsThe inappropriate prophylactic use of PPIs during the perioperative period is common. Regulation authorities and pharmacists should take more targeted measures to promote the rational prophylactic use of PPIs during the perioperative period.

To examine the prevalence of residents receiving proton pump inhibitors (PPIs) for evidence-based indications in a large sample of Italian nursing homes (NHs) and to assess the predictors of potentially inappropriate prescriptions. This study was conducted in a sample of Italian long-term care NHs. Information on drug prescription, diseases, and socio-demographic characteristics of NH residents was collected three times during 2018. Appropriate use of PPI was defined in accordance with the strongest evidence-based indications and the Italian criteria for PPI prescription. Among the 2579 patients recruited from 27 long-term care NHs, 1177 (45.6%) were receiving PPIs; 597 (50.7%) were taking them for evidence-based indications. Corticosteroids, anticoagulants, and mean number of drugs were the most important predictors of inappropriate PPIs prescriptions. NH residents receiving ≥13 drugs had about 10 times the risk of receiving a PPI than those taking 0 to 4 drugs. Similarly, residents with more comorbidity had about 2.5 times the risk of receiving a PPI than those in better health. The prevalence of residents inappropriately treated with PPI in individual NHs varied widely, ranging from 22% to 63%. Number of drugs, comorbidity, corticosteroids, and anticoagulants are the most important predictors of the inappropriate use of PPI in NHs. The wide variability between NHs in the appropriate use of PPIs suggests the need for thorough drug review in this fragile and vulnerable population. Prescribing patterns linked to evidence-based guidelines and national recommendations are essential for rational, cost-effective use of PPIs.

Proton pump inhibitors (PPIs) contribute to polypharmacy and are associated with adverse effects. As prospective data on longitudinal patterns of PPI prescribing in older patients with multimorbidity are lacking, we sought to assess patterns of PPI prescribing and deprescribing, as well as the association of PPI use with hospital admissions over 1 year in this population. We conducted a prospective, longitudinal cohort study using data from the Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM) trial, a randomized controlled trial testing an intervention to reduce inappropriate prescribing (2016-2018). This trial included adults aged 70 years and older with at least 3 chronic conditions and prescribed at least 5 chronic medications. We assessed prevalence of PPI use at time of hospital admission, and new prescriptions and deprescribing at discharge, and at 2 months and 1 year after discharge, by intervention group. We used a regression with competing risk for death to assess the association of PPI use with readmissions related to their potential adverse effects, and all-cause readmission. Overall, 1080 (57.4%) of 1879 patients (mean age 79 yr) had PPI prescriptions at admission, including 496 (45.9%) patients with a potentially inappropriate indication. At discharge, 133 (24.9%) of 534 patients in the intervention group and 92 (16.8%) of 546 patients in the control group who were using PPIs at admission had deprescribing. Among 680 patients who were not using PPIs at discharge, 47 (14.6%) of 321 patients in the intervention group and 40 (11.1%) of 359 patients in the control group had a PPI started within 2 months. Use of PPIs was associated with all-cause readmission (n = 770, subdistribution hazard ratio 1.31, 95% confidence interval 1.12-1.53). Potentially inappropriate use of PPI, new PPI prescriptions and PPI deprescribing were frequent among older adults with multimorbidity and polypharmacy. These data suggest that persistent PPI use may be associated with clinically important adverse effects in this population.

BackgroundLong-term inappropriate use of proton pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD) and dyspepsia is a common issue that can lead to unnecessary healthcare costs and potential adverse effects. Alternative treatments, such as episodic alginate therapy, may offer a more cost-effective and clinically appropriate approach.ObjectiveTo investigate the financial impact of transitioning patients from long-term inappropriate PPI use to episodic alginate treatment for GERD and dyspepsia, from the perspective of the National Health Service (NHS) England.MethodsA budget impact model was used to compare costs over a 5-year period for adult patients using long-term inappropriate PPIs, with and without alginate treatment. By the fifth year, 20% of patients were assumed to have switched to alginate treatment. In this model, the base case analysis included only drug costs, while a scenario analysis also considered adverse effect costs.ResultsOver the 5-year period, net savings of £11.5 million were observed in drug acquisition costs when 20% of patients (4.8 million) successfully transitioned to alginate treatment. When adverse effect costs were included in the scenario analysis, net savings increased to £16.6 million due to a slight reduction in the number of adverse effects. One-way sensitivity analysis confirmed the robustness of these results.ConclusionsTransitioning patients from long-term PPI use to episodic alginate treatment is beneficial for patients, potentially reducing adverse effects, and can lead to significant budgetary cost savings, which can be reallocated.

Introduction. Overutilization of Proton Pump Inhibitors (PPIs) both in ambulatory care and in the inpatient setting possesses economic implications and increases the risk for adverse drug reactions. This study was undertaken to identify factors associated with inappropriate PPI use among consecutively unplanned admissions of elderly patients at the time of admission. Materials and Methods. In 758 patients (54.2% women), mean age 80.3±8.0 (M±1SD), demographic characteristics, and medical and medication history were recorded. Parametric tests and multiple logistic regression analysis were applied to identify the predictors of inappropriate PPI use. Results. 232 patients (30.6%) were receiving PPIs. 37 (4.9%) were receiving PPIs appropriately and 195 (25.7%) were receiving PPIs without a proper indication. Consequently, PPIs prescribing was inappropriate in 195/232 (84%). Moreover, 512 patients (67.5%) were not receiving PPIs appropriately and 14 patients (1.8%) were not receiving PPIs but they had a proper indication. When we compared patients receiving PPIs without a proper indication with those who were not receiving PPIs, a statistical difference was found according to Charlson Comorbidity Index (p≤0.001, U=37922.00), number of diseases (p≤0.001, U=33269.00) and medications (p≤0.001, U=31218.50), Katz Index score (p=0.01, U=45328.00), and the use of blood thinners (p≤0.001, χ2=21.15). In multivariate analysis the only independent predictor of inappropriate PPI use was the number of medications (p=0.001, OR=1.16, 95%CI 1.06-1.27). Conclusions. The main predictor of inappropriate PPI use was the number of received medications. Εfforts needed to apply the predefined criteria for PPI prescription and to deprescribe PPIs received inappropriately.

Proton pump inhibitors (PPIs) are widely prescribed for acid-related disorders; however, concerns have emerged regarding their misuse, particularly in patients with liver cirrhosis. This study aimed to assess the appropriateness of PPI prescriptions in patients with cirrhosis and to identify factors contributing to their overutilization in this patient population. In this cross-sectional study, 1000 patients with cirrhosis receiving PPIs were enrolled. Data on demographics, clinical parameters, and endoscopic findings were collected, and indications for PPI therapy were assessed according to established guidelines. Among patients with cirrhosis, 60.5% were prescribed PPIs, with pantoprazole being the most prescribed (55.7%). Inappropriate PPI use was observed in 53.6% of the patients, mainly because of lacking an approved indication (78.54%) or exceeding the recommended treatment duration (21.46%). Causes contributing to misuse included prolonged PPI use postendoscopic band ligation (29.1%), extended treatment for functional dyspepsia (21.46%), failure to discontinue PPIs upon hospital discharge (17.54%), using PPIs for preventing portal hypertensive gastropathy (PHG) or variceal bleeding (16.42%), and stress ulcer prophylaxis in non-ICU patients (15.86%). Multivariate analysis identified independent predictors of inappropriate PPI use, including Child classification C, Mayo End-Stage Liver Disease score greater than 18, hepatocellular carcinoma, and previous variceal bleeding, whereas hematemesis was identified as an independent predictor of appropriate use. This study underscores the prevalent inappropriate prescription of PPIs in patients with liver cirrhosis, particularly in those with advanced liver disease or a history of variceal bleeding. Enhancing prescribing practices and adhering to evidence-based guidelines are essential to mitigate the risks associated with PPI misuse in patients with cirrhosis.