Overuse Of Proton Pump Inhibitors Research Articles

Is over-use of proton pump inhibitors fuelling the current epidemic of Clostridium difficile-associated diarrhoea?

Many developed countries have seen an increase in cases of Clostridium difficile-associated diarrhoea (CDAD) in recent years. This has occurred despite heightened awareness of the risks of broad-spectrum antibiotics, overall reduction in antibiotic use and increased focus on hospital hygiene. Some of the increase is due to the introduction of new hypervirulent strains, but it predates the description of these. The epidemic coincides with increased use of proton pump inhibitors (PPIs), much of which is inappropriate according to UK and other national guidelines. Gastric acid is a key host defence against other gastrointestinal infections and epidemiological and animal studies have demonstrated a positive association between incident CDAD and PPI use. An association with recurrence of CDAD after initially successful treatment has also been found. Vegetative C. difficile cells are rapidly killed at normal gastric pH, but survive at the pH found in patients taking PPI. It has recently been shown that vegetative organisms survive long enough on moist surfaces for transmission between patients to occur. We conclude that restricting PPI use to patients with an appropriate indication would reduce unnecessary expenditure on these agents, and might be an additional means of controlling the current epidemic of CDAD.

Use and Abuse of Proton Pump Inhibitors

Purpose: To determine the utilization of proton pump inhibitors (PPIs) at an academic medical center we evaluated the indications for PPI use in hospitalized patients, and the frequency in which patients placed on a PPI during hospitalization were discharged on a PPI. Methods: We performed a prospective analysis of 502 consecutive patients admitted at the Medical College of Georgia (MCG) and the Children's Medical Center (CMC) who received a PPI. Patients who were on a PPI at home and not placed on one at the time of admission were not accounted for in this study. We recorded demographics, indication for use, hospital service prescribing PPI, route of administration, PPI use prior to admission, and discharge PPI medication for each admission. Results: Between May 6th and June 19th, 2005, a total of 2,497 patients were admitted to MCG and CMC. 502 were prescribed a PPI. Analysis of the adult population revealed 463 (26%) patients admitted to MCG were prescribed a PPI. Patients received a PPI for the following indications: stress ulcer prophylaxis (SUP)-53%, GERD-30%, not documented -15%, GI bleed-5%, continuation of home medication-4%, other-4%, esophagitis-0.1%, and peptic ulcer disease-0.1%. 37% of patients were on a PPI prior to admission. Although 246 patients (53%) were placed on a PPI for prophylactic purposes, only 18% were admitted to the intensive care unit. Overall, 300 of the 463 patients (∼65%) were prescribed a PPI without a documented appropriate indication. Upon discharge, 50% of patients were prescribed a PPI. 22% of patients placed on a PPI for prophylactic purposes were discharged on a PPI. Overall, about 55% of patients were discharged on a PPI without appropriate indication or documentation. Conclusion: There is significant overuse of PPIs in the inpatient setting at our institution with about 26% of patients receiving a PPI on admission, and 55% of patients discharged on a PPI without any clear indication or documentation. Caution must be used when initiating PPI therapy in the hospital setting; long-term therapy often continues unnecessarily after discharge leading to increased healthcare costs, polypharmacy, and increased risk for potential adverse effects including Clostridium difficile diarrhea, community-acquired pneumonia, and intestinal bacterial overgrowth. Therefore, physicians need to be aware of the indications and possible consequences of PPI use in hospitalized patients.

Overuse of proton pump inhibitors.

There have been concerns raised about the potential adverse effects of proton pump inhibitors, especially with long-term use. In particular, their potent action can suppress the features and delay the diagnosis of gastric cancer, while prolonged exposure may hasten the development of gastric carcinoids. To examine the use of proton pump inhibitors in patients at the major teaching hospital in Tasmania, Australia, principally to determine the appropriateness of the therapy according to published guidelines. A retrospective review of the medical records of all patients prescribed any of the proton pump inhibitors at the hospital over a 7-month period, was performed. An extensive range of demographic and clinical variables was recorded for each patient. The patients were also asked a series of questions during their hospitalization to extract some of the relevant information - in particular, if and when they had undergone endoscopy. The 200 patients (52% males) had a mean age of 69 +/- 16.4 years. The most common indications for using proton pump inhibitors were acute gastrointestinal bleeding (20.9%), severe refractory ulcerating oesophagitis (17.3%), mild/moderate oesophageal reflux (17.3%) and refractory peptic ulcer (11.7%). A large number of patients were using a proton pump inhibitor for 'other' indications (39.6%). The prescribing of proton pump inhibitors satisfied the approved indications, as outlined in the Australian Schedule of Pharmaceutical Benefits, in only 37.1% of cases. Endoscopy had been performed in 54.1% of patients prior to commencing therapy with a proton pump inhibitor and within the next 7 days in another 12.8% of patients. Only 59% of patients had previously been treated with an H2-receptor antagonist before commencing therapy with a proton pump inhibitor. Even worse, only 58.5% of patients had used an H2-receptor antagonist before a proton pump inhibitor for mild/moderate oesophagitis. The median duration of proton pump inhibitor therapy for patients admitted to the hospital and already receiving one of the drugs was 450 days. Over half of the patients were being concurrently treated with other drugs which are known to cause or exacerbate gastro-oesophageal disease, and 18% were smokers. Whereas the proton pump inhibitors are undoubtedly effective agents, studies of their prescribing in practice consistently suggest over-use prior to endoscopy, use in patients who do not fit the approved criteria, and prescribing for indications in which 'less powerful' agents should have been sufficiently effective for the patient's symptoms. This poses economic and safety concerns, particularly in light of the suggestion that these drugs could delay the diagnosis of gastric cancer.