Indication For Proton Pump Inhibitor Use Research Articles

Proton-pump inhibitors are associated with an increased risk of asthma: A nationwide nested case-control study.

Background: Proton-pump inhibitors (PPI) are among the most widely used drugs worldwide. However, the association between PPI use and the risk of asthma remains unclear. Objective: To investigate the association between PPI use and subsequent asthma risk. Methods: We included participants from the Taiwan National Health Insurance Research Database between 1999 and 2013. Patients who used PPIs and experienced new-onset asthma (n = 20,344) were assigned to the case cohort and matched in a 1:1 ratio with controls who did not subsequently develop asthma. PPI use was defined as > 30 cumulative defined daily doses (cDDD); non-PPI use was defined as ≤ 30 cDDDs. The Charlson Comorbidity Index (CCI) score was used for clinical prognosis and comorbidity adjustment. Multivariate Cox regression models were used for the calculation of adjusted odds ratios (OR). Results: There was a significant and dose-dependent association between PPI use and the risk of developing asthma. The adjusted ORs were 1.24 (95% confidence interval [CI], 1.15-1.33), 1.39 (95% CI, 1.28-1.50), and 1.61 (95% CI, 1.43-1.81) for the male subject with 31-120 cDDDs, 120-365 cDDDs, and >365 cDDDs, respectively, compared with PPI nonusers. Men were at higher risk of developing asthma with longer PPI use compared with women. Stratified analyses based on the PPI type showed that exposure to lansoprazole, pantoprazole, omeprazole, and esomeprazole was associated with subsequent asthma risk. Conclusion: Extended use of PPIs was found to be linked to an increased risk of asthma development. This association remained consistent across different age groups, sexes, demographic factors, indications for PPI use, CCI scores, and other atopic diseases. However, further prospective studies are required to elucidate the causal mechanisms involved.

Impact of transitioning to an active, noninterruptive CYP2C19/proton pump inhibitor alert on prescribing patterns.

To compare rates of prescriber acceptance of interruptive and noninterruptive clinical decision support (CDS) alerts regarding potential diminished therapeutic effectiveness and safety risks associated with proton pump inhibitor (PPI) use in carriers of gene variants affecting cytochrome P450 (CYP) isozyme 2C19 metabolism. A retrospective study was conducted at a large rural health system to examine different approaches to improving CDS alert acceptance while minimizing alert fatigue. Manual reviews were conducted to identify alerts regarding CYP2C19 metabolizer status displayed at the time of PPI ordering over 30-day periods before and after the transition from interruptive to noninterruptive CDS alert functionality. A chi-square test was conducted to analyze prescriber acceptance of CDS recommendations by alert modality and type of treatment modification. Overall, interruptive alerts had an acceptance rate of 18.6% (64/344), compared to 8.4% acceptance (30/357 alerts) for noninterruptive alerts (P ≤ 0.0001). Analysis of acceptance criteria -revealed the noninterruptive alert cohort had higher acceptance, as determined by documented medication dose adjustments, than the interruptive alert cohort (53.3% [16/30] and 4.7% [3/64], respectively). The difference in acceptance rates by CDS modality and treatment modification was statistically significant (P ≤ 0.00001). The predominant indication for PPI use was gastroesophageal reflux disease (GERD) in both cohorts. Interruptive alerts that actively influenced workflow had higher acceptance rates than noninterruptive alerts that served an informational purpose without a direct disruption of workflow. The study results suggest the utilization of noninterruptive alerts may be a beneficial tool for prompting clinicians to alter dosing regimens rather than transition to an alternative agent.

Use of proton pump inhibitors in scandinavian children and adolescents: An observational study.

To examine the use of proton pump inhibitors (PPIs) in Scandinavian children with focus on the geographical variation, temporal changes and possible contributing factors to observed changes. An observational population-based study of children and adolescents (1-17 years) in Norway, Sweden, and Denmark during the period 2007-2020. Information concerning dispensed PPIs was obtained from the national prescription databases of each country and presented as means per 1,000 children for each country and calendar year in four age categories (1-4, 5-9, 10-13 and 14-17 years). In 2007, the PPI use in children was similar across Scandinavian countries. An increased PPI use was observed in all countries during the study period, with gradually increasing differences between the countries. In general, Norway showed both the largest total increase and the largest increase in each age category compared to Sweden and Denmark. In 2020 Norwegian children showed, on average, a 59% higher PPI use compared to Swedish children and a more than double the overall dispensation rate than Denmark. In Denmark there was a 19% reduction in dispensed PPIs from 2015 to 2020. Despite being countries with similar health care systems and without indications of increased incidence of gastroesophageal reflux disease (GERD), we observed considerable geographical variation and temporal changes of PPI use in children. Although this study did not contain data on the indication for PPI use, these large differences across countries and time may indicate a current overtreatment.

425 Is the Use of Proton Pump Inhibitors Associated With Increased Risk of Ischemic Stroke: A Systematic Review and Meta-Analysis

INTRODUCTION: The use of proton-pump inhibitors (PPIs) has been associated with various adverse effects including increased risk of major adverse cardiovascular events, community acquired clostridium difficile infection, chronic kidney disease and dementia. Some studies over the past decade have suggested an association between PPIs use and ischemic stroke. METHODS: We pooled the data after comprehensive literature search from the PubMed, Embase, Cochrane Library and Scopus databases using ‘proton pump inhibitors’ AND ‘stroke’ as the keywords. RevMan was used for the entry and analysis of data. A random effects model was created given the significant heterogeneity of the included studies and a funnel plot was made to assess the publication bias. Our primary objective was to study whether all-comers patients on PPIs are at an increased risk of stroke. Sub-group analysis was also done to investigate the association between patients on dual anti-platelet therapy [DAPT] (aspirin and clopidogrel) with or without PPIs and stroke. RESULTS: After searching 774 titles, 25 titles were selected to be included in the systematic review and 15 articles for the meta-analysis. Our pooled analysis of 155,406 patients (46,652 patients on PPI and 101,892 patients without PPI found a positive association between the use of PPI and stroke (odds ratio = 1.28, 95% confidence interval = 1.12, 1.48, P = 0.001) [Figure 1]. Given the significant heterogeneity of the studies (I2= 60%) a sub-group analysis was done which also suggested an increased risk of stroke associated with PPI use among patients on dual antiplatelet therapy (OR: 1.43, 95% CI: 1.26, 1.66, p< 0.001, I2= 11%) [Figure 2]. Analysis of the included randomized controlled trials revealed an OR: 1.47, 95% CI: 0.66, 3.25 but the results were not statistically significant (p< 0.81) [Figure 3]. CONCLUSION: In a pooled analysis of over 155,000 patients we found a positive association between the use of PPIs and stroke. Our results are limited by significant heterogeneity and retrospective study design of the observational studies. Rigorous clinical trials are needed to establish the safety of PPIs in relation to stroke, especially among patients on DAPT. Until definitive data emerges, patients on DAPT are probably best served by being off PPIs or being on alternative acid suppression regimen, unless there is a compelling indication for PPI use.

Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study

ObjectiveTo estimate all cause mortality and cause specific mortality among patients taking proton pump inhibitors (PPIs).DesignLongitudinal observational cohort study.SettingUS Department of Veterans Affairs.ParticipantsNew users of PPIs (n=157 625) or H2...

The risks of long-term use of proton pump inhibitors: a critical review.

Proton pump inhibitors (PPIs) are among the most frequently prescribed medications. Their use is likely even higher than estimated due to an increase in the number of PPIs available without a prescription. Appropriate indications for PPI use include Helicobacter pylori infection, erosive esophagitis, gastric ulcers, and stress ulcer prevention in high-risk critically ill patients. Unfortunately, PPIs are often used off-label for extended periods of time. This increase in PPI usage over the past two decades has called into question the long-term effects of these medications. The association between PPI use and infection, particularly Clostridium difficile and pneumonia, has been the subject of several studies. It’s proposed that the alteration in gastrointestinal microflora by PPIs produces an environment conducive to development of these types of infections. At least one study has suggested that long-term PPI use increases the risk of dementia. Drug interactions are an important and often overlooked consideration when prescribing any medication. The potential interaction between PPIs and antiplatelet agents has been the subject of multiple studies. One of the more recent concerns with PPI use is their role in the development or progression of chronic kidney disease. There is also some literature suggesting that PPIs contribute to the development of various micronutrient deficiencies. Most of the literature examining the potential adverse effects of PPI use is composed of retrospective, observation studies. There is a need for higher quality studies exploring this relationship.

Is There a Reason for the Proton Pump Inhibitor? An Assessment of Prescribing for Residential Care Patients in British Columbia

The use of proton pump inhibitors (PPIs) may cause significant harm to patients in the residential care setting, as these patients are often frail with multiple morbidities. The extent of non-evidence-based use of PPIs in residential care sites of the Fraser Health Authority in British Columbia is unknown. To determine the proportion of non-evidence-based use of PPI therapy for residential care patients of the Fraser Health Authority. This retrospective cross-sectional study was conducted in 6 Fraser Health residential care facilities in British Columbia between April 1, 2015, and March 31, 2016. Two definitions of "evidence-based indications" were used. The first definition encompassed broad evidence-based indications for PPI use, specifically gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), gastritis, esophagitis, Barrett esophagus, and gastrointestinal protection from concurrent oral steroids, oral nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. The second definition involved common evidence-based indications for PPI use, specifically GERD or PUD. Descriptive statistics were used to evaluate the primary outcome: the proportion of PPI orders without a documented broad or common evidence-based indication for PPI treatment. A total of 331 residential care patients and 407 PPI orders were assessed. The proportion of PPI orders without a documented broad evidence-based indication was 16.2% (66/407). The proportion of PPI orders without a documented common evidence-based indication was 43.7% (178/407). The most frequently documented reason for a PPI order was GERD (214/407 or 52.6%). PPI orders for patients with GERD and gastrointestinal bleeding had the longest duration of therapy during residential care admission, averaging 205.1 and 218.1 days, respectively. About 1 in 6 PPI orders for Fraser Health residential care patients did not have a documented broad evidence-based indication, and about 2 in 5 PPI orders did not have a documented common evidence-based indication. These results indicate a need to assess the appropriateness of therapy for every patient with an active PPI order in residential care facilities.

Quantifying Candidacy for Deprescribing of Proton Pump Inhibitors among Long-Term Care Residents

Proton pump inhibitors (PPIs) are a commonly prescribed drug class used to inhibit gastric acid secretion. They are prescribed for both treatment and prophylaxis of several gastrointestinal conditions. Although PPIs can be used safely in the short term, several serious adverse effects have been reported following long-term use, including increased risk of falls and fragility fractures. Long-term care home (LTCH) residents represent a population in which the long-term adverse effects of PPIs can be significant and PPI deprescribing should be considered when appropriate. To determine the proportion of LTCH residents with PPI prescriptions who were eligible for PPI deprescribing, and to examine vitamin B12 deficiencies and fall risk in the study population. This cross-sectional, multisite chart review involved LTCH residents who had an active PPI prescription during October 2016. A convenience sample of 150 charts was randomly selected, and the appropriateness of PPI deprescribing was determined using Canadian guidelines. Descriptive statistics were used to examine demographic characteristics, PPI dosing and indication, vitamin B12 supplementation, fall history, and fall risk. Three of the selected charts were excluded because of missing information. Of the 147 residents included in the chart review, 93 (63%) were candidates for deprescribing. PPI use for gastroesophageal reflux disease for more than 8 weeks without a deprescribing attempt in the past year was the most frequently observed opportunity for deprescribing (49/93 [53%]). Twenty-nine residents (20%) had no documented indication for PPI use. Thirteen residents (9%) had had a fall within the past 30 days, and 53 (36%) had a prescription for vitamin B12 supplements and/or had low serum vitamin B12 levels. A majority of the residents whose charts were reviewed were candidates for PPI deprescribing. This finding suggests an opportunity for clinicians who care for LTCH residents to increase their deprescribing efforts.

Inappropriate use and overuse of PPIs: A strategy for discontinuation

Proton pump inhibitors (PPIs) have risks associated with long-term use, yet they are used chronically by more than 20 million Americans and account for more than $10 billion in health care spending.1https://apha.us/IMSInstituteGoogle Scholar Data on the effects of long-term PPI use are still emerging, but potential consequences include increased risk of vitamin and mineral deficiencies, bone fractures, changes in gut microbiota, Clostridium difficile–associated diarrhea, pneumonia, dementia, chronic kidney disease, gastric atrophy (higher risk among those with Helicobacter pylori infections), and gastric cancer. Overprescribing PPIs is common, with as many as 68.8% of patients being prescribed a PPI inappropriately at hospital discharge2J Manag Care Pharm. 2010; 16: 122-129PubMed Google Scholar and 36% to 39% of ambulatory patients lacking an indication for PPI use.3Am J Manag Care. 2010; 16: e228-e234PubMed Google Scholar, 4Am J Gastroenterol. 2003; 98: 51-58Crossref PubMed Scopus (113) Google Scholar As pharmacists, we can make an impact on inappropriate use and overuse of PPIs. At Central Pharmacy in Durham, NC, we initiated a service as part of a residency project to tackle the issue of PPI overuse. Our approach is to taper the PPI gradually while increasing the duration between each step to improve successful PPI discontinuation. The taper involves use of compounded omeprazole capsules, which allows the patient to decrease their PPI dose by 5 mg every 2 weeks. This regimen is also accompanied by lifestyle changes and supplements to support digestion and gastrointestinal (GI) health. Abrupt withdrawal of PPIs results in successful discontinuation in only 14% to 27% of patients who have used these medications for 8 weeks.5Eur J Gastroenterol Hepatol. 2010; 22: 1182-1188Crossref PubMed Scopus (26) Google Scholar, 6Int J Family Med. 2015; 2015: 175436Crossref PubMed Google Scholar Our goal is to have a higher success rate by tapering more gradually. Patients on step-down therapy with omeprazole 20 mg daily for 1 week, omeprazole 10 mg for 1 week, and omeprazole 10 mg every other day for 1 week saw slightly higher success rates, with 31% achieving discontinuation.7Aliment Pharmacol Ther. 2006; 24: 945-954Crossref PubMed Scopus (117) Google Scholar For our PPI discontinuation service, we first establish patient interest and eligibility. Patients ineligible for PPI discontinuation include those with Barret’s esophagus, Zollinger–Ellison disease, Los Angeles grade C or D erosive esophagitis, or idiopathic peptic ulcer disease. Other ineligible patients are those on nonselective NSAIDs at high risk of a GI bleed, those on COX-2 selective NSAIDs with a prior GI bleed, and those on antiplatelet therapy at high risk of a GI bleed. Once eligibility is determined, patients schedule a consult with a pharmacist to determine trigger foods and the potential need for supportive supplements on the basis of patient-specific symptoms. The patient’s daily PPI dose is converted to omeprazole equivalents to calculate the taper regimen that will be requested from the physician. If the patient receives 20 mg of omeprazole equivalent each day, their regimen will consist of omeprazole 15 mg for 2 weeks, omeprazole 10 mg for 2 weeks, and finally omeprazole 5 mg for 2 weeks. Patients are also provided with 5-mg capsules for breakthrough reflux symptoms. Follow-up with a pharmacist occurs by phone every 2 weeks to align with the time frame of the taper regimen. These phone calls assess patient symptoms and determine if any adjustments need to be made to the plan. We encourage patients to call the pharmacist whenever they need to report symptoms that are not responding to the breakthrough omeprazole. This project is under way, and as it progresses, we will collect metrics on frequency of rebound symptoms and success rate of discontinuation at 1, 3, and 6 months after conclusion of the PPI taper.

The appropriate use of proton-pump inhibitors.

The introduction of proton-pump inhibitors (PPIs) into clinical practice since about thirty years has greatly improved our therapeutic approach to acid-related diseases for their well recognized efficacy and safety. Accordingly, the role of surgery has been enormously reduced in this field. The main indications for PPI use are universally acknowledged by many scientific societies and are the following: treatment of gastroesophageal reflux disease in its various forms and complications, eradication of H. pylori infection in combination with two or more antibiotics, therapy of H. pylori-negative peptic ulcers, healing and prevention of NSAID-associated gastric ulcers, co-therapy with endoscopic procedures to control upper digestive bleeding and medical treatment of Zollinger-Ellison Syndrome. Despite the above well-defined indications, however, the use of PPIs continues to grow every year in both Western and Eastern countries and this phenomenon poses serious queries about the appropriate prescription of these drugs worldwide. In fact, the endless expansion of PPI market has created important problems for many regulatory authorities for two relevant features: the progressive and irreversible increase of the costs of therapy with this class of drugs and the greater potential harms for the patients. So, there is the need for a reappraisal of PPI correct indications for both general practitioners and various specialists in order to re-establish a correct use of these effective drugs in daily clinical practice, according to the best evidence-based guidelines.

The use of proton pump inhibitors among older adults with intellectual disability: A cross sectional observational study

BackgroundOlder people with Intellectual Disability (ID) have a high prevalence of gastrointestinal conditions such as Gastro-Oesophageal Reflux Disease (GORD). However, despite this, information about treatment, in particular the use of Proton Pump Inhibitors (PPIs), in this population is sparse and limited. ObjectiveTo investigate the prevalence and pattern of PPI use among older people with ID. MethodData on PPI use and key demographics was analysed from Wave 2 (2013/2014) of IDS-TILDA, a nationally representative longitudinal study of 677 participants aged 40 years and above in Ireland. Descriptive statistics, bivariate analyses and binary logistic regression were carried out. ResultsJust over a quarter, 27.9% (n = 189), of participants reported use of PPIs, and 53.4% (n = 101) were female. The largest proportion of PPI users (53.4%) were aged between 50 and 64 yrs. Most of the PPIs were used in maximum doses (66.7%). However only 43.9% of PPI users had an indication for PPI use (GORD, stomach ulcer or/and an NSAID use), and further 13.2% were also taking an antiplatelet agent. Use among those in residential care homes (54.3%) was much higher than for those living independently or with family (7%). PPI use among those who have severe/profound ID was 25% higher than those with mild ID. Information about the length of PPI use was missing for 31.2%, but of those with data, just over half recorded using the PPIs for more than a year. Apart from an indication, the factors associated with PPI use were older ages (≥50 years), severe/profound level of ID. ConclusionPPI use among older people with intellectual disability is prevalent and frequently long term, often without a clear indication. PPI use especially among those with severe/profound ID and those who live in residential care homes, could predispose these individuals to additional comorbidities and in order to avoid inappropriate long term of use regular review is required.

Physicians’ Practice Toward and Knowledge about Proton Pump Inhibitor Prescription in Jeddah, Saudi Arabia

Proton pump inhibitors (PPI) are acid-suppressive agents widely prescribed to patients with common gastrointestinal symptoms. The common belief that PPI have a safe profile and high efficacy level leads to PPI over-prescription. However, the physicians’ knowledge about PPI could also contribute in this over-prescription. Thus, this study aimed to evaluate physicians’ practice towards and knowledge about PPI prescription in Jeddah, Saudi Arabia. A cross-sectional, questionnaire-based survey was conducted. The participants were randomly recruited from our hospital, Jeddah, Saudi Arabia between August and December 2013. The questionnaire comprised 15 items in three sections: questions regarding general background, practice of PPI prescription, and knowledge on PPI safety. The data were coded, entered, and analysed using the Statistical Package for the Social Sciences software (SPSS), version 23.0.0. The results were presented as frequencies and percentages. In total, 112 physicians responded, and 58% reported prescribing PPIs to patients. Omeprazole was the preferred PPI prescribed. Only 20% of physicians consistently warned patients about the possible adverse effects. One-third reported that they discontinued PPIs after reassessment. Gastroesophageal reflux disease and peptic ulcer disease were the most common indications for PPI use. Approximately 60% of physicians prescribed PPIs for <6 months. Physician’s knowledge about PPI adverse effects and drug–drug interactions were low. As a conclusion, physicians in our hospital showed low knowledge and poor adherence to guidelines regarding PPI prescription. Therefore, staff awareness programs and prescribing guidelines are required to ensure good clinical practice.

No Significant Association Between Proton Pump Inhibitor Use and Risk of Stroke After Adjustment for Lifestyle Factors and Indication

Proton pump inhibitors (PPI) are among the top 10 most prescribed medications worldwide. We investigated the association between PPI use and ischemic stroke. We collected data on 68,514 women (mean age, 65 ± 7 years) enrolled in the Nurses' Health Study since 2000 and 28,989 men (mean age, 69 ± 8 years) in the Health Professionals Follow-up Study since 2004, without a history of stroke. We used Cox proportional hazards models to examine the association between risk of incident stroke and PPI use among participants. The primary end point was first incident stroke. In the 2 cohorts, we documented 2599 incident strokes (2037 in women and 562 in men) over a 12-year period, encompassing 949,330 person-years. After adjustment for established risk factors for stroke, PPI use was associated with a significant increase in risk of ischemic stroke (hazard ratio, 1.18; 95% confidence interval, 1.02-1.37). The association was reduced after we adjusted for potential indications for PPI use, including history of peptic ulcer disease, gastroesophageal reflux disease, or gastrointestinal bleeding, and prior use of histamine-2 receptor antagonist therapy (hazard ratio, 1.08; 95% confidence interval, 0.91-1.27). Regular PPI use was not associated with increased risk of stroke overall or hemorrhagic stroke. In an analysis of data from the Nurses' Health Study and the Health Professionals Follow-up Study, we did not find a significant association between PPI use and ischemic stroke, after accounting for indications for PPI use. Prior reports of an increased risk of stroke may be due to residual confounding related to chronic conditions associated with PPI use.

Missed Opportunities for Attempts at De-escalation of Proton Pump Inhibitor Therapy

Introduction: Proton pump inhibitors (PPI) are one of the most widely prescribed classes of medication in the United States. Long term treatment with a PPI is appropriate in patients with Barrett's epithelium and a high risk for gastrointestinal (GI) bleeding. Attempts should be made to reduce or discontinue PPI use in individuals maintained on PPIs for other indications. This study evaluated the frequency of gastroenterologists' attempts to de-escalate PPI therapy when appropriate. Methods: A retrospective chart review of randomly selected records during a 1 year periods of patients prescribed a PPI >6 months seen by a gastroenterologist at an urban university medical center was conducted. Data was collected to determine the indication for PPI use, reason for clinic visit and documentation of a de-escalation discussion. De-escalation was defined as attempts at reduction in dose, reduction in frequency, or complete PPI discontinuation. Patients prescribed PPIs for Barrett's esophagus and GI bleeding were excluded. A Microsoft Excel database maintaining subject confidentiality was used. Statistical analysis performed using a two-tailed Fisher's Exact Test, with significance set at p < 0.05. Results: A total of 600 charts were initially reviewed, of which, 324 were included in the analysis. Of the 324 patients, 141 patients were prescribed a PPI by a gastroenterologist. 72 out of 141 were seen for GERD, and 69 seen for non-GERD reasons. 29 patients (40%) seen for GERD had documented discussions of de-escalation, compared to 12 (17%) of patients being seen for non-GERD reasons. There were more frequent attempts (p=0.0031) to de-escalate long-term PPI use when the patient was seen for GERD compared to when seen for a non-GERD indication. Conclusion: It is recommended that patients maintained on long term PPIs without an indication for chronic use should have an attempt to de-escalate their therapy. Our data show that gastroenterologists more consistently attempt PPI de-escalation when patients are seen for GERD management compared to when patients have appointments for non-GERD conditions (40% vs 17%, p=0.0031). While PPIs are quite safe, and overall, well tolerated, potential adverse effects have been well documented. There may be missed opportunities to de-escalate of discontinue PPI use in patients on chronic PPI treatment when seen in clinic for management of non-GERD conditions.

Establishing PPI Stewardship Among Internal Medicine Residents in a Large Outpatient Clinic: A Follow-up Study

Introduction: Over the past several years, concerns have been raised about excessive use of proton pump inhibitors (PPIs). In 2009, a study done at our teaching institution revealed that PPIs were prescribed in about a third of patients, often without clear indication. An effort was then established to decrease overprescribing of PPIs by creating an awareness among internal medicine residents through educational lectures, email reminders and posting flyers in different clinic areas. Purpose of our current study was to assess recent PPI use in comparison to 2009, and to determine the success of these efforts alone in establishing PPI stewardship among residents. Methods: We randomly selected 254 outpatient medical records from January 2015-December 2015 to review. The percentage of patients receiving PPIs and mean daily milligram dose were determined. Indications for PPI use were evaluated based on history and/or findings on upper endoscopy. Key findings of this study were compared to the 2009 results.Table: Table. Upper Gastrointestinal DisordersTable: Table. Comparison of PPI prescribingResults: Two hundred fifty-four records were reviewed, mean age 55.9 years (± 13.2), 51.0% male, 85.3% Caucasian. During 2015, 93 (36.6%) were taking PPIs, compared to 83/259 (32.0%) in 2009 (P = 0.28). The most commonly prescribed PPIs were esomeprazole (61.2%), pantoprazole (46.2%), and omeprazole (33.3%). Mean daily dose (MDD) of esomeprazole was 36.1 (± 12.8) mg in 2015 vs 39.0 (± 6.3) mg in 2009 (P = 0.19). MDD of pantoprazole was 36.3 (± 11.8) mg vs 40.0 (± 0.0) mg in 2009 (P = 0.38). MDD of omeprazole was 29.5 (± 15.3) mg vs 22.0 (± 4.2) mg in 2009 (P = 0.14). GERD was listed as the primary diagnosis in 51 (54.8 %) of PPI patients, but unconfirmed in 26 (51%) vs 46% in 2009 (P = 0. 77). Use of PPIs forgastroprotection was documented in four (4.3%). Conclusion: Despite of our efforts to educate residents regarding PPI stewardship, the level of PPI prescribing and dosing has not decreased over the past several years. These findings seem to reflect current unimpressive national PPI prescribing trends. It is concluded that a more aggressive approach involving multidisciplinary teams at the institutional level is vital in establishing PPI stewardship to minimize adverse effects and costs.

Chronic gastritis: Instructions for use of medications

The paper highlights the features of drug use in the legal aspect. It analyzes instructions for medical use of proton pump inhibitors (PPIs) and gastric protective agents. Taking into account the characteristics of indications registered in the instruction, the authors discuss the possibility of using various PPIs. The instruction for medical application is an official document approved by the Ministry of Health, the basis of which is the data of trials carried out by a manufacturer, and it should be a key or fundamental source for a physician in choosing a medication. The use of a drug with no indications given in the manual (the so-called 'off-label' use in foreign practice), is a clinical trial of a sort conducted by a physician individually, by taking upon himself/herself a legal liability. If arguments break out over the correct choice of this or that drug in treating the specific patient, the instruction containing the indications for use of specific medications to treat a specific disease is one of the proofs that the physician has correctly chosen the drug or a criterion for skilled medical care. The inclusion of chronic gastritis as a primary and only diagnosis into the primary documentation substantially limits the possibilities of using PPIs. When a PPI is indicated for therapy of erosive gastritis, a formal rationale is contained only in the instruction for use of Controloc. There are no registered indications for PPI use to treat chronic non-erosive gastritis; the gastric protective agent Rebagit is indicated.

Proton Pump Inhibitors Are Not Associated With Acute Kidney Injury in Critical Illness.

Recent epidemiologic data linking proton pump inhibitor (PPI) use to acute and chronic kidney dysfunction is yet to be validated in other populations, and mechanisms have not been explored. Using a large, well phenotyped inception cohort of 15 063 critically ill patients, we examined the risk of acute kidney injury (AKI), as defined by the Kidney Disease Improving Global Outcomes criteria guidelines, according to prior use of a PPI, histamine-2 receptor antagonist (H2 RA), or neither. A total of 3725 (24.7%) patients reported PPI use prior to admission, while 905 (6.0%) patients reported H2 RA use. AKI occurred in 747 (20.0%) and 163 (18.0%) of PPI and H2 RA users respectively, compared to 1712 (16.2%) of those not taking acid suppressive medications. In unadjusted analysis, PPI and H2 RA users had a 28% (95%CI 1.17-1.41, P< .001) and 10% (95%CI 0.91-1.30, P = .31) higher risk of AKI compared to those taking neither class of medication. However, in sequential models that included adjustment for demographics, cardiovascular comorbidities, indications for PPI use, and severity of illness, the effect of PPI on the risk of AKI was attenuated, and in the adjusted analysis, PPI was not associated with AKI (OR 1.02; 95%CI 0.91-1.13, P = .73). The presence of sterile pyuria and hypomagnesemia did not modify the association between PPI use and AKI. In summary, after adjustment for demographics, illness severity, and the indication for PPI use, PPI use prior to admission is not associated with critical illness AKI.

Feasibility of a patient-centered deprescribing process to reduce inappropriate use of proton pump inhibitors.

Proton pump inhibitors (PPIs) are inappropriately prescribed in up to 50% of users. Systematic medication review and cessation of inappropriate medications or deprescribing may improve patient outcomes and reduce costs. The aim of this study was to assess the feasibility of a patient-centered deprescribing process in a population of adults with complex polypharmacy. This was a prospective feasibility study. Participants were recruited from hospital outpatient clinics. The patient-centered deprescribing process consisted of 5 steps: comprehensive medication history, identification of potentially inappropriate medications, determining if the medication can be ceased, planning the withdrawal regimen (eg, tapering where necessary), and provision of monitoring, support, and documentation. Feasibility was determined by assessing time taken to complete the different steps of the deprescribing process and participant feedback. In all, 57 PPI users were recruited; participants were 70 ± 14 years old and took 14 ± 6 medications. The indication for PPI use was verified in 43 participants and judged as potentially inappropriate in 19 (44%); 8 were suitable for trial withdrawal, and 6 consented. All 6 successfully ceased (n = 3) or reduced (n = 3) their PPI use, and this was sustained at 6 months postintervention in 4 participants. The patient-centered deprescribing process can safely reduce inappropriate PPI prescribing in a small proportion of people. Although the process was acceptable to participants, difficulties in accessing complete medical histories, time limitations, and minimal evidence to support effectiveness in certain indications were barriers to implementation of the process in clinical practice.

Association between proton pump inhibitor use and spontaneous bacterial peritonitis in cirrhotic patients with ascites.

There are data suggesting a link between proton pump inhibitor (PPI) use and the development of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites; however, these data are controversial. To assess whether the use of PPIs in cirrhotic patients with ascites is associated with an increased risk for SBP. A retrospective case-control study (June 2004 to June 2010) was conducted at the Centre Hospitalier de l'Université de Montréal in Montreal, Quebec. Fifty-one cirrhotic patients admitted with paracentesis-proven SBP (≥250 neutrophils/mm3), occurring within seven days of hospital admission, met the inclusion criteria. These patients were matched 1:2 (for age, Child-Pugh class and year of admission) with 102 comparable cirrhotic patients with ascites who were admitted for conditions other than SBP. Patients with SBP had a significantly higher rate of pre-hospital PPI use (60.8%) compared with cirrhotic patients without SBP (42.2%; P=0.03). On multivariate analysis, PPI use was the only factor independently associated with SBP (OR 2.09 [95% CI 1.04 to 4.23]; P=0.04). Thirty-five (35%) patients in both groups had no documented indication for PPI use in their charts. Forty-five percent of the remaining cirrhotic patients with SBP had an inappropriate indication, as defined in the protocol, for PPI use compared with 25% of controls. Cirrhotic patients with SBP were twice as likely to have taken PPIs than patients without SBP. These findings reinforce the association between PPI use and SBP observed in other studies. A high percentage of cirrhotic patients were taking a PPI without any documented indication.

Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are one of the most commonly prescribed classes of medications in the United States. By inhibiting gastric H/K adenosine triphosphatase via covalent binding to the cysteine residues of the proton pump, they provide the most potent acid suppression available. Long-term PPI use accounts for the majority of total PPI use. Absolute indications include peptic ulcer disease, chronic nonsteroidal anti-inflammatory drugs use, treatment of Helicobacter pylori, and erosive esophagitis. Although PPIs are generally considered safe, numerous adverse effects, particularly associated with long-term use have been reported. Many patients receiving chronic PPI therapy do not have clear indications for their use, prompting consideration for reduction or discontinuation of their use. This article reviews the indications for PPI use, the adverse effects/risks involved with their use, and conditions in which their use is controversial.