Prescribing Of Pump Inhibitors Research Articles

P137 A multinational survey to identify the clinicians perspectives concerning proton pump inhibitors in patients with systemic sclerosis

Abstract Background/Aims Proton Pump Inhibitors (PPIs) are widely used in Systemic Sclerosis (SSc) for the treatment of gastroesophageal reflux disease (GERD). However, there is scarce evidence to support their use while long-term safety has been questioned. The aim of our study was to identify healthcare providers’ perspectives and experience regarding PPIs therapy in SSc patients. Methods An online survey in English language targeting clinicians involved in the care of SSc patients, was developed and distributed through social media and international physician networks. The survey was launched on 27th November 2022 and kept open for three weeks. Results Responses from 227 clinicians from 36 countries were recorded: most of them (86%) were between 30-70 years and gender was equally represented (F: 52%; M: 48%). The majority ‘agreed’ (41%) or ‘strongly agreed’ (45%) that GERD is a major cause of morbidity in SSc. Lifestyle modifications and non-pharmacological approaches alone were seldom (16%) considered effective. Only half of respondents ‘agreed’ (43%) or ‘strongly agreed’ (11%) there is solid evidence supporting PPIs efficacy in SSc. A range of PPIs was prescribed by clinicians, most frequently pantoprazole (74%), esomeprazole (72%), omeprazole (72%), and lansoprazole (68%). The most common reasons for PPIs prescription (Table 1) were symptomatic GERD unresponsive to lifestyle modification (95%), objective evidence of GERD (82%), and hoarseness or respiratory symptoms (71%). Multiple concerns were raised about PPI long-term safety. The three highest (mean, 10 being very concerned) reasons were: small intestinal bacterial overgrowth (5.5), osteoporosis (5.4), and drug interactions (5.2). There were significant differences in attitudes towards surgery for refractory GERD: ‘strongly disagreed’ (14%), ‘disagreed’ (26%) ‘neutral’ (52%), ‘agreed’ (13%), ‘strongly agreed’ (3%). Furthermore, half of respondents had concerns about potential complications (i.e., worsening of dysphagia): ‘disagreed’ (26%) or ‘strongly disagreed’ (6%), ‘neutral (52%), ‘agreed’ (13%), ‘strongly agreed’ (3%). Conclusion Our survey confirms that PPIs are frequently prescribed for GERD in SSc patients, despite the absence of randomized clinical trials demonstrating their efficacy and safety. Clinicians are concerned about side effects, especially regarding long-term use. There is significant heterogeneity in attitudes towards surgery for refractory GERD. Future research and practical treatment recommendation are urgently needed. Disclosure G. Bandini: None. A. Alunno: None. F. Oliveira Pinheiro: None. C. Campochiaro: None. I. Galetti: None. P. Matucci Cerinic: None. B. Ruaro: None. A. Moggi Pignone: None. L. Dagna: None. M. Matucci Cerinic: None. Z. McMahan: None. M. Hughes: None.

A multi-national survey to identify clinicians’ perspectives concerning Proton Pump inhibitors in patients with systemic sclerosis

ObjectivesProton Pump Inhibitors (PPIs) are widely used in SSc for gastroesophageal reflux disease (GERD). However, there is little evidence to support their empirical use and long-term safety has been questioned. Our objective was to better describe clinicians’ attitudes toward PPIs prescription and use in SSc patients. MethodsClinicians involved in the care of SSc patients were invited through international physician networks and social media to participate in an online survey. ResultsResponses from 227 clinicians from 36 countries were evaluable. The majority ‘agreed’ (41.4 %) or ‘strongly agreed’ (45.4 %) that GERD is a major cause of morbidity in SSc. Lifestyle modifications are seldom (16 %) considered effective. Only half ‘agreed’ (43 %) or ‘strongly agreed’ (11 %) there is solid evidence supporting PPIs efficacy in SSc. The most common reasons for PPIs prescription were symptomatic GERD unresponsive to lifestyle modification (95 %), objective evidence of GERD (82 %), and hoarseness or respiratory symptoms (71 %). There are variable concerns about PPIs long-term safety in SSc. The three highest (mean) reasons (0–10, here 10 is ‘very concerned’) were: small intestinal bacterial overgrowth (5.5), osteoporosis (5.4), and drug interactions (5.2). There are significant differences in attitudes towards surgery for refractory GERD, and concerns about potential complications. PPIs may have a putative role for disease modification (e.g., ILD and calcinosis), and the role of immunosuppression is uncertain for GI (gastrointestinal) disease in SSc. ConclusionPPIs are frequently prescribed in SSc. Side effects are a recognized concern, especially regarding long-term therapy. There is significant variation in attitudes towards surgical intervention. Future research and practical treatment recommendation for PPIs in SSc are urgently needed.

Proton pump inhibitor prescribing patterns and utilization: A retrospective chart review analysis

IntroductionProton pump inhibitors (PPIs) show a high level of efficacy and a high safety profile, and they have been increasingly prescribed in recent years. However, recent pharmacoepidemiological evidence has shown that PPI use has been associated with health risks and complications. ObjectivesThis study aimed to assess the prescribing patterns of proton pump inhibitors and the prevalence of potential drug–drug interactions (DDIs) among patients who use PPIs. MethodThis was a retrospective analysis of electronic health records from the Ministry of National Guard Hospitals in Riyadh from January 2019 to June 2022. All adult patients who used PPIs were included to assess the prescribing patterns and drug utilization, including the number of prescriptions, duration of prescriptions, number of doses, and prescription indications. Potential DDIs were assessed based on concurrent use, which is defined as taking an interacting drug parallel to PPIs. The assessment includes complete or partial overlapping, with at least one day of overlapping. ResultsThe total number of PPI prescriptions was 80,365 for a total of 9,930 patients with a mean age of 67.5. The majority of PPIs were prescribed in high doses (74%), without reporting appropriate indications (95%), and 17% were prescribed for long-term use. A total of 24,575 (33.6%) potential DDIs with PPIs were found. ConclusionThe results showed that the majority of the PPI prescriptions were made with a high number of doses, without reporting appropriate indications, with some having potential DDIs. This might result in exposing patients to an increasing number of health risks. The findings highlight the importance of implementing a stewardship program for PPI prescription with periodic reassessments of patients’ needs for these medications.

Proton Pump Inhibitor Use Before and After a Diagnosis of Inflammatory Bowel Disease.

Proton pump inhibitors (PPIs) have an impact on the gut microbiome. We investigated whether increased use of PPIs was associated with a diagnosis of inflammatory bowel disease (IBD). The University of Manitoba IBD Epidemiology Database includes all Manitobans diagnosed with IBD between 1984 and 2018 with age-, sex-, and geography-matched control subjects and comprehensive prescription drug data from April 1995. Subjects were considered to be users if they received 2 PPI prescriptions. We assessed PPI prescriptions prediagnosis and for 3 years postdiagnosis of IBD. The absolute and relative rates were calculated and compared for PPI use pre- and post-IBD diagnosis. A total of 5920 subjects were diagnosed with IBD after April 1996. Rates of PPI use in control subjects increased gradually from 1.5% to 6.5% over 15 years. Persons with IBD had a higher rate of PPI use, peaking up to 17% within 1 year of IBD diagnosis with a rate ratio (RR) of 3.1 (95% confidence interval [CI], 2.9-3.3). Furthermore, persons with Crohn's disease (RR, 4.2; 95% CI, 3.7-4.6) were more likely to have been PPI users prediagnosis than persons with ulcerative colitis (RR, 2.4; 95% CI, 2.2-2.7). Important predictors of increased PPI use were older age, year of data collection, and Crohn's disease diagnosis. Persons with IBD have higher PPI use preceding their diagnosis. Possibly, the use of a PPI alters the gut microbiome, increasing the risk for IBD diagnosis; or persons with IBD have increased rates of dyspepsia, warranting PPI use; or some IBD symptoms are treated with PPIs whether warranted or not.

Evolution of the consumption trend of proton pump inhibitors in the Lleida Health Region between 2002 and 2015

BackgroundProton pump inhibitors (PPIs) are one of the most commonly prescribed pharmacological groups. Their high prevalence and duration of use are of important health concern due to the risk they can cause to patients. Despite these risks, their use remains particularly high, especially in the elderly population. We determined the trend in the prevalence of PPI consumption in the population of the Lleida Health Region between 2002 and 2015 to explore patterns of use and associated characteristics.MethodsAn analysis of secular trends between 2002 and 2015 was performed. The database included all individuals who used PPIs in the Lleida Health Region, which had 358.070 inhabitants in 2015. PPI use was evaluated using prescription dispensing data from the public health system. All types of PPIs approved by the pharmaceutical agency were included. Trends were investigated by age and sex.ResultsFor the whole study period, a total of 215,417 individuals accounted for 292,122 dispensations. Overall, 48% were women, and the mean age was 62 years. The dispensing prevalence of PPI use in 2015 was 18.0% overall—20.4% for women and 15.7% for men—and was 54.6% for those over 65 years. In terms of the subtypes of PPIs, 16.8% of prescriptions were for omeprazole, 0.66% were for pantoprazole, and 0.48% were for lansoprazole. The evolution of the annual PPIs dispensation prevalence showed a progressive increase from 11.3% in 2002 to 18.0% in 2015, which was attributable to an increase in the use of omeprazole (9.0% vs. 16.8%) and, to a lesser extent, esomeprazole (0.02% vs. 0.4%).ConclusionAn increase in the prevalence of PPI dispensation was observed over 14 years of follow-up. The prevalence of dispensation was especially high for the population older than 65 years, despite the risk of cognitive decline and falls. Comprehensive actions are required to to increase rational prescribing of PPIs, especially in high-risk populations.

256 USE OF PROTON PUMP INHIBITORS ON SPECIALIST GERIATRICS UNITS

Abstract Background Proton Pump Inhibitors (PPIs) prescriptions have increased more than 100% in the past decade. Prior research estimates that only a third of PPI prescriptions are appropriate in older adults. Geriatric patients have increased rates of polypharmacy and adverse drug events. PPIs are associated with significant harms including a higher fracture risk, increased risk of infection and vitamin and electrolyte abnormalities. We aimed to examine the PPI prescribing practice in a Specialist Geriatric Unit (SGU), identify patterns of inappropriate use and reduce inappropriate prescriptions. Methods Medical records, kardexes and prescriptions were reviewed for 66 patients admitted in the Special Geriatric Units between April and May 2021. Variables included gender, age, ordinary residence (nursing home or home) and diagnosis on admission. PPI indication was grouped according to symptoms, OGD in the last year, H. Pylori testing in last year and reason/diagnosis leading to PPI prescription. Name and dose of PPI, route of administration and duration of treatment were noted. Results 38 patients (57.6%) were on a PPI. The mean age was 81.7 years. 79% of the patients were on the PPI at the time of hospital admission. Over 85% of the patients on PPI had no OGD or H. Pylori testing in the last year. Only 42% had a diagnosis justifying the use of PPI (only 25% of whom had their diagnosis confirmed by appropriate investigations). 90% of the patients were on PPI for more than a year. Conclusion Inappropriate use of PPIs remains common in the Specialist Geriatric Units. PPI prescriptions need to be optimized so as to reduce harmful effects on geriatric patients. Following a multifaceted PPI deprescribing intervention repeat audit is now planned.

Proton Pump Inhibitor Use Increases Pyogenic Liver Abscess Risk: A Nationwide Cohort Study.

Background/AimsProton pump inhibitors (PPIs) increase gastric pH and alter the gut microbiome. An increased risk for infectious diseases has been reported in PPI users. However, little is known about the association of PPI use with pyogenic liver abscess (PLA) incidence risk.MethodsWe conducted a population-based cohort study using data from a nationwide representative sample of the Korean general population followed up for 10 years (January 1, 2003 to December 31, 2013). We identified PPI prescriptions and considered PPI as a time-varying variable. Proportional hazards regression model was used for incident PLA comparing PPI use versus non-use. Propensity score matching was also conducted.ResultsDuring the 4 209 229 person-years of follow-up, 58 595 participants had at least 1 PPI prescription and 541 patients developed liver abscess. The age-, sex-, residential area-, and income-adjusted hazard ratio for PLA incidence with PPI use was 4.19 (95% CI, 2.54-6.92). The association was observed in fully adjusted models (hazard ratio 3.88; 95% CI, 2.33-6.44). The positive association between PPI use and PLA was consistent in all subgroups analyzed and in propensity score matching group.ConclusionThe present data indicate that PPI use is associated with an increased PLA risk. Therefore, it is necessary to prescribe PPIs with clear indication and to avoid improper use of PPIs.

Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use

BackgroundProton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients.MethodsUsing the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients’ charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention.ResultsDuring the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers’ perception that PPIs are low priority medications and patients’ willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment.ConclusionIn a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale.

Proton pump inhibitor use and appropriateness analysis: a snapshot from a secondary care hospital

Abstract Objectives Proton pump inhibitors (PPIs) have become one of the most frequently prescribed drugs since their introduction 30 years ago. Effectiveness and safety profile of PPIs has led to their overutilization and has exposed patients to a number of potential risks. The objective of this study was to evaluate the use of PPIs in a secondary care hospital in the United Arab Emirates. Methods This prospective observational drug-utilization study was conducted in patients receiving treatment with PPIs and admitted to internal medicine wards of the study site. Electronic patient case records were reviewed and data on PPI prescribing was collected and analysed. Appropriateness of PPI use was assessed as per international guidelines. Key findings Out of 172 patients enrolled, 53.5% were females with median age of 57 years (34.3, 71.0). Four different PPIs were prescribed to study patients, pantoprazole (86.6%), esomeprazole (5.8%), rabeprazole (4.1%) and omeprazole (3.5%). Ninety-two (53.5%) patients were prescribed intravenous PPI, whereas 80 (46.5%) patients were given PPI in oral form. Overall, 103 (59.9%) patients had inappropriate PPI prescriptions. Of these inappropriate prescriptions, 22 patients had no clear indication for PPI use and for 16 patients; PPIs were indicated for stress ulcer prophylaxis in low-risk category. Corticosteroid use [odds ratio (OR): 4.34, 95% confidence interval (CI): 1.22–15.46; P = 0.023] was significantly associated with greater odds of inappropriate PPI use. Conclusions We report a high prevalence of inappropriate PPI prescribing among the hospitalized patients in our study. Inappropriate PPI prescribing is a concerning issue and collective efforts should be made to check and minimize the same.

A79 PROVINCIAL DATA IN ALBERTA REVEAL A CLEAR NEED TO ADDRESS OVERPRESCRIBING OF PROTON PUMP INHIBITORS

Abstract Background Proton pump inhibitors (PPIs) are among the most commonly prescribed drugs in Canada. They are effective for several upper GI-disorders, have a very favorable safety profile and therefore there are few barriers to prescribing. Concern about overuse of PPIs has been growing. Many patients do not need long term treatment. Patients starting PPI should receive short term therapy (e.g. 8 weeks) and if they respond the need for long term therapy needs to be determined. The usual starting dose is once a day for most indications. Evidence suggests a lack of ongoing indication for PPI in 40–55% of primary care patients.There are economic implications of overuse of PPIs. Public drug spending on PPIs in Canada totaled $288.3 million of $13.5 billion spent in 2017. Aims To analyze prescribing data for all PPI prescriptions in Alberta for the years 2017–18 and 2018–19 and 2019–2020, to document number of prescriptions &amp;gt;60 days, the number of new versus repeat prescriptions, proportion of new prescriptions at a greater than 1x daily dose, the proportion of prescriptions written by primary care physicians and to estimate the number of prescriptions targetted for deprescribing. Methods Data were obtained anonymously from the Pharmaceutical Information Network (PIN) database from community based pharmacies in Alberta. PPIs were identified using DIN numbers. Prescribed dose and duration were obtained, as well as data on repeat prescriptions. The number of prescriptions that could be targeted for deprescribing was also estimated. Results The results are shown in table 1. More than 10% of the population receives a prescription each year. Of these 25–31% were new prescriptions and 69–75% were refills. The percentage of patients who were prescribed PPIs for more than 60 days was 26–28%. Furthermore, 23% of all prescriptions had a defined daily dosage greater than the recommended standard dose of once a day therapy for most indications.75% of all prescriptions are written by family physicians. Conclusions Prescription rates of PPIs are very high in Alberta and 75% of patients are on longer term therapy. There likely is significant overprescribing of PPIs, estimated to be up to 40% of patients filling PPI prescriptions in Alberta. This represents a significant avoidable medication and system burden and patient costs. The starting dose of new prescriptions is also high, despite the fact that for most indications the daily dose should be 1x a day. A 20% reduction in prescribing would save at least $ 9 million in Alberta. A deprescribing project has been initiated by the Digestive Health Strategic Clinical Network, a multi-stakeholder network, which addresses important GI issues in Alberta. Funding Agencies None

Reduction of the long-term use of proton pump inhibitors by a patient-oriented electronic decision support tool (arriba-PPI): study protocol for a randomized controlled trial

BackgroundProton pump inhibitors (PPIs) are increasingly being prescribed, although long-term use is associated with multiple side effects. Therefore, an electronic decision support tool with the aim of reducing the long-term use of PPIs in a shared decision-making process between general practitioners (GPs) and their patients has been developed. The developed tool is a module that can be added to the so-called arriba decision support tool, which is already used by GPs in Germany in routine care. In this large-scale cluster-randomized controlled trial we evaluate the effectiveness of this arriba-PPI tool.MethodsThe arriba-PPI tool is an electronic decision support system that supports shared decision-making and evidence-based decisions around the long-term use of PPIs at the point of care. The tool will be evaluated in a cluster-randomized controlled trial involving 210 GP practices and 3150 patients in Germany. GP practices will be asked to recruit 20 patients aged ≥ 18 years regularly taking PPIs for ≥ 6 months. After completion of patient recruitment, each GP practice with enrolled patients will be cluster-randomized. Intervention GP practices will get access to the software arriba-PPI, whereas control GPs will treat their patients as usual. After an observation period of six months, GP practices will be compared regarding the reduction of cumulated defined daily doses of PPI prescriptions per patient.DiscussionOur principal hypothesis is that the application of the arriba-PPI tool can reduce PPI prescribing in primary care by at least 15% compared to conventional strategies used by GPs. A positive result implies the implementation of the arriba-PPI tool in routine care.Trial registrationGerman Clinical Trials Register, DRKS00016364. Registered on 31 January 2019.

2389. Assessing the Time Course of Proton Pump Inhibitor Use and Clostridioides difficile Infection

BackgroundProton pump inhibitors (PPIs) are a known risk factor for Clostridioides difficile infection (CDI) and recurrence, even in the absence of antibiotic use. No studies have specifically assessed the increased risk for CDI based on PPI duration, given that PPIs are frequently newly prescribed during hospitalizations and infrequently discontinued, even when CDI has occurred. The aim of this project was to assess the time course of PPI utilization and risk of CDI.MethodsWe conducted a retrospective matched case–control study comparing patients who developed CDI (cases) with patients who did not develop CDI (controls, matched on age, gender, date of admission and hospital location) from a cohort of patients with a C.difficile PCR test order from an academic medical center. Patient charts were reviewed for PPI use prior to the date of the positive test and whether the PPI was started in the hospital or as a home medication (>30d, 30–90d, 90–180d, >180d). The primary comparison was odds of PPI use between cases and controls using conditional logistic regression adjusted for antibiotic exposure (SAS 9.4, Cary, NC).ResultsA total of 348 patients were included in the study, 174 cases and 174 matched controls. 65% of patients in the study received a PPI, 85% a PPI or H2 blocker and 95% of patients received antibiotics during their admission. Patients on PPIs as home medications were not at an increased risk of CDI (OR = 1.08 (95% CI 0.60–1.93)) compared with those not on PPIs. Patients whose PPIs were initiated in the hospital were at increased risk of CDI compared with those not on PPIs (OR = 1.4 (95% CI 0.81–2.41)). No significant difference was observed across time periods of PPI use prior to admission and development of CDI.ConclusionPatients who started PPIs during inpatient stays were at a higher risk of developing CDI than patients not exposed to PPIs. However, PPI use was not found to be significantly associated with CDI in this analysis, regardless of the time or duration of PPI prescription. The results may be confounded by the high frequency of PPI use and concomitant antibiotic use in both cases and controls. Further study is needed to evaluate the impact of short-course PPI prescriptions in inpatient settings on CDI.Disclosures All authors: No reported disclosures.

193 Audit on Inappropriate Prescribing of Proton Pump Inhibitors Amongst Patients over 65 Years in an Acute Rehabilitation Hospital

Abstract Background Proton pump inhibitors (PPIs) are one of the most frequently prescribed drug classes in the older person. Indications for PPI use are outlined in the NICE guidelines, however they are often prescribed without an appropriate indication resulting in increased healthcare costs and increased exposure to potential adverse clinical effects. Methods To determine the rate of inappropriate prescribing of PPI’s, an audit was carried out to assess the incidence of inappropriate prescribing in an Acute Rehabilitation facility pre and post Education to Hospital Doctors. An audit was carried out, pre and post intervention, on patients over the age of 65 years admitted to an acute rehabilitation hospital between 2018 and 2019. Patient’s medical charts were reviewed and data was collected on PPI prescribing. Results Cycle 1-Pre Education; 83 people included in the audit. Mean age was 80.8 years[SD ±9]. 43% of patients were on a PPI, all of which were prescribed the generic form. 83.4% of patients had no indication for PPI use. Of the 16.6%, indications included GORD, Barrett’s oesophagus, PUD and PPI prophylaxis against NSAID’s including aspirin. 77.7% were on therapeutic dose without any indication. 100% of patients were on PPI for longer than 6 weeks. Cycle 2, Post education: 86 patients were included in re-audit. Mean age was 81.5[SD ±10]. 60.4% of patients were on PPI. Of those, 55% had no indication for PPI. Of the 44% on PPI, indications were similar to those in Cycle 1. 83% of patients were on PPI longer than 6 weeks. 56.5% were on inappropriate dose of PPI. Conclusion This audit highlighted the inappropriate prescribing of PPI’s in the older person. By providing education to Doctors about NICE PPI prescribing guidelines, overall rate of inappropriate prescribing of PPI decreased by 28.4% and accurate dosing of PPI improved by 21.2%.

Appropriateness of proton pump inhibitor use in patients admitted under the general medical unit

AbstractBackgroundProton pump inhibitors (PPI) are extensively prescribed internationally and in Australia. However, minimal information is available on the appropriateness of PPI use in the general medical population.AimThis study determined the proportion of general medical unit (GMU) inpatients taking a PPI on admission and evaluated the appropriateness of these PPI prescriptions.MethodsA single‐centre prospective observational study was conducted from 6 June to 11 July 2016. Consecutive patients were screened, and those taking a PPI prior to admission were included, whereas those not taking a PPI formed the control cohort. Appropriateness of PPI use was evaluated by: (1) reviewing for concordance with the Australian Therapeutic Guidelines and National Prescribing Service Guidelines on PPI use in gastro‐oesophageal reflux disease; (2) assessment of indication, dose and treatment duration by an expert panel consisting of two general physicians and one senior pharmacist.ResultsAmong 440 consecutive GMU patients, 198 (45.0%) were taking a PPI on admission. Of these, 66.2% had an inappropriate indication, dose or treatment duration. The largest category of inappropriate PPI use was excessive treatment duration (43.4%). In terms of comorbid conditions, PPI users had a higher prevalence of osteoporosis and/or history of fracture (42.9% vs 27.2%; p &lt; 0.001) and hypomagnesaemia (10.6% vs 3.4%; p = 0.003).ConclusionInappropriate PPI use is highly prevalent among GMU inpatients. Given the potential for adverse effects, unnecessary health expenditure and pill burden, strategies should be developed to aid clinicians to consistently consider the utility of continuing long‐term PPI prescriptions in each patient's situation.

Changes in proton pump inhibitor prescribing trend over the past decade and pharmacists\u2019 effect on prescribing practice at a tertiary hospital

BackgroundProton pump inhibitors (PPIs) remain one of the world’s most frequently prescribed medications and there is a growing number of publications on correct versus incorrect use of PPIs worldwide. The objective of this observational retrospective study was to assess changes in PPI prescribing trends over the past decade and pharmacists’ effect on optimizing PPI prescribing practice at a tertiary hospital in China.MethodsWe collected the prescriptions of PPIs in our hospital from January 2007 to December 2016. Then the rate of PPI prescribing, the defined daily doses (DDDs) and expenditures were calculated and plotted to show the change in utilization of and expenditure on PPIs. Reasons behind this change and effect of pharmacists’ intervention were evaluated by investigating the rationality of PPI use through sample surveys of patients of pre-intervention (Jul.-Dec. 2015) and post-intervention (Jul.-Dec. 2016).ResultsIn outpatient settings, the rate of PPI prescribing remained almost constant, utilization (from 135,808 DDDs to 722,943 DDDs) and expenditure (from 1.85 million CNY to 7.96 million CNY) increased for the past ten years, dominated by oral formulations and rabeprazole. In contrast, in inpatient settings, the rate of PPI prescribing (from 20.41 to 37.21%), utilization (from 132,329 DDDs to 827,747 DDDs) and expenditure (from 3.15 million CNY to 25.29 million CNY) increased from 2007 to 2015 and then decreased, dominated by injection formulations and omeprazole. Pharmacist interventions could significantly promote the rational use of PPIs (44.00% versus 26.67%), decrease PPI use and reduce patients’ charges (P < 0.05).ConclusionsThe utilization of and expenditure on PPIs grew due to the increase of patients and irrational use of PPI. Pharmacist interventions help to reduce PPI utilization and expenditure and enhance rationality for inpatients, but much work should be done to regulate injection and originator formulas, and improve the rationality in the future.

Impact d’une évaluation des pratiques professionnelles sur la pertinence des prescriptions d’inhibiteurs de la pompe à protons à l’hôpital

IntroductionProton pump inhibitors (PPI) are widely prescribed for unrecognized indications, at high a dose and for a long duration, in spite of side effects and numerous drug interactions. In 2009, the HAS (French Health Authority) published recommendations of good prescription but the latter are poorly respected. In this context of over prescription and additional cost for the society, we performed a professional practice evaluation of on the model of the Deming wheel. The objective of this work was to optimize the relevance of the prescriptions of the IPP in two services of internal medicine and geriatrics through an evaluation of the professional practices. All PPI prescriptions introduced in outpatient visits or during hospitalization were analyzed. Patients and methodsData collection was prospective, over two periods of 2 months and included 163 (first phase), then 139 patients (second phase). An assessment grid of PPI prescriptions was completed by physicians regarding the active substance, the dose, the duration and the indication of the prescription. The relevance of the prescription corresponded to PPI with a conformed indication and duration and to the prescriptions no recommended stopped. Following the first period of data collection, information was given to medical students and physicians on the relevance of their prescriptions with regard to the current recommendations and informative flyers were offered with the aim of improving the practices before the second period of evaluation (second phase). ResultsDuring the first phase, only 25% of the pre-hospital prescriptions and 33% of the hospital prescriptions respected the HAS recommendations. The main indication of the PPI was the prevention of peptic ulcers in a context of associated drug estimated at risk. An improvement of the global relevance of prescription was observed after awareness of the physicians: 26% relevance during the first phase and 60% in the second one (P<0.012). During the second phase, the part of PPI prescriptions introduced at hospital decreased from 33 to 17% and the discontinuation of the not corresponding prescriptions increased from 6 to 33%, with an additional information given to the general practitioner (P<0.001). However, during the second phase, 33% of the prescriptions introduced in hospitalization were always not corresponding and 61% of the not corresponding prescriptions begun in outpatient visits were always pursued on discharge, probably due to the lack of sufficient information to stop the prescription. ConclusionOur study underlines the frequent disrespect of the indications in the prescription of PPI. Interestingly, a professional practices evaluation improved the relevance of the prescriptions with a more frequent withdrawal of the not corresponding exposure and a decrease in global not corresponding prescriptions. Our study suggests that it is crucial to regularly inform physicians on the good prescription of PPI. Patient information focused on the indications and the limited duration of PPI prescription, potentially severe side effects of chronic exposure and on the risk of drug interactions also remains necessary in order to facilitate the stop of the exposure and restrict self-medication.

Multifaceted intervention to curb in-hospital over-prescription of proton pump inhibitors: A longitudinal multicenter quasi-experimental before-and-after study

BackgroundProton pump inhibitors (PPIs) are indicated for a restricted number of clinical conditions, and their misuse can lead to several adverse effects. Despite that, the proportion of overuse is alarmingly high. ObjectiveTo test the efficacy of a multifaceted strategy in order to achieve a significant reduction of new PPI prescriptions at discharge in hospitalized patients. DesignMulticenter longitudinal quasi-experimental before-and-after study conducted from July 1st, 2014 to June 30th, 2017. Participants44,973 admissions in a network of 5 public teaching hospitals of the Italian-speaking region of Switzerland. InterventionMultifaceted strategy consisting in a continuous transparent monitoring-benchmarking and in capillary educational interventions applied in the internal medicine departments. To confirm the causality of the results we monitored the trend of new PPI prescriptions in the, not exposed to the intervention, surgery departments of the same hospital network. Main measuresNew PPI prescriptions at hospital discharge. Key resultsOver the 36month study period 44,973 patient files were analyzed. At admission, comparing internal medicine vs. surgery departments, 44.9% vs. 23.3% of patients were already being treated with a PPI. The annual rate of new PPI prescriptions, for internal medicine showed a decreasing trend: 19, 19, 18, 16% in years 2014, 2015, 2016, 2017, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001), while an increasing rate was found in the surgery departments in the same years: 30, 29, 36, 36%, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001). The case mix was significantly associated with the probability of new PPI prescriptions in both departments (OR1.35, 95% CI 1.26–1.44 for internal medicine and 1.24, 95% CI 1.19–1.30 for surgery). ConclusionsThe introduction of a multifaceted intervention significantly reduced the time trend of PPI prescriptions at hospital discharge in internal medicine departments. Further studies are needed to confirm whether the strategy proposed could contribute to optimize the in-hospital drug prescription behavior in other healthcare settings as well.

Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study

ObjectiveProton pump inhibitors (PPIs) is associated with worsening of gastric atrophy, particularly in Helicobacter pylori (HP)-infected subjects. We determined the association between PPIs use and gastric cancer (GC) among HP-infected...

Appropriateness of Proton Pump Inhibitor prescription in patients admitted to hospital: Attitudes of general practitioners and hospital physicians in Italy

IntroductionProton pump inhibitor (PPI) prescriptions have raised concern for both huge increase of health expenditure and possible long-term adverse effects. ObjectiveTo evaluate appropriateness of PPI prescription in ambulatory and hospital care. DesignObservational cohort study. PatientsPatients admitted to the Internal Medicine Unit of Bologna S. Orsola Hospital between 15/09/2013 and 15/12/2013. Data on clinical condition and drug therapy were collected at three time points: admission (reflecting GP's prescription), hospital stay and discharge. Main measuresAppropriateness of PPI use was evaluated as follows: (1) agreement between PPI use/non-use and appropriate clinical condition; (2) in PPI users, assessment of Medication Appropriateness Index (MAI). Differences in appropriateness among time points were analyzed by chi-square test. Logistic regression model was used to identify possible determinants of PPI appropriateness. Key resultsAmong 280 patients, 56% received PPI at least once in the three time points. Appropriateness, according to indication of use, was similar between admission and hospital stay (61% vs. 62%; p=0.82) and between hospital stay and discharge (62% vs. 59%; p=0.94). MAI score showed important, although statistically non-significant, change in appropriateness between admission and hospital stay (20% vs. 28%; p=0.16). Age≥65 was always associated with appropriate PPI use (up to OR=4.37; p<0.01), whereas cardiovascular comorbidity and conditions requiring analgesic treatment influenced appropriateness only at admission (OR=3.84; p<0.01 and OR=0.34; p<0.01, respectively). ConclusionsHospital clinicians only rarely reconsidered GP's choice to prescribe PPI. Room for improvement in PPI appropriateness is represented by (1) assessing gastrointestinal risk in each patient under analgesics and anti-inflammatory drugs, and (2) short-term re-evaluation of PPI prescription after discharge.

The effect of dose and type of proton pump inhibitor use on risk of fractures and osteoporosis treatment in older Australian women: A prospective cohort study

ObjectivesProton pump inhibitors (PPIs) are among the most prescribed medications worldwide, however, there is growing concern regarding potential negative effects on bone health. The aim was to examine the effect of dose and type of PPI use on subsequent use of osteoporosis medication and fractures in older Australian women. MethodsData were included from 4432 participants (born 1921–26) in the 2002 survey of the Australian Longitudinal Study on Women's Health. Medication data were from the national pharmaceutical administrative database (2003–2012, inclusive). Fractures were sourced from linked hospital datasets available for four major States of Australia. Competing risk regression models used PPI exposure as a time-dependent covariate and either time to first osteoporosis medication prescription or fracture as the outcome, with death as a competing risk. ResultsOf the 2328 PPI users and 2104 PPI non-users, 827 (36%) and 550 (26%) became users of osteoporosis medication, respectively. PPI use was associated with an increased risk of subsequent use of osteoporosis medication (adjusted sub-hazard ratio [SHR]=1.28; 95% confidence interval [CI]=1.13–1.44) and subsequent fracture (SHR=1.29, CI=1.08–1.55). Analysis with PPI categorized according to defined daily dose (DDD), showed some evidence for a dose–response effect (osteoporosis medication: <400 DDD: SHR=1.23, CI=1.06–1.42 and ≥400 DDD: SHR=1.39, CI=1.17–1.65, compared with non-users; SHRs were in the same range for fractures). Esomeprazole was the most common PPI prescribed (22.9%). Analysis by type of PPI use showed an increased subsequent risk for: (1) use of osteoporosis medication for rabeprazole (SHR=1.51, CI=1.08–2.10) and esomeprazole (SHR=1.48, CI=1.17–1.88); and (2) fractures for rabeprazole (SHR=2.06, CI=1.37–3.10). Users of multiple types of PPI also had increased risks for use of osteoporosis medication and fractures. ConclusionAn appropriate benefit/risk assessment should be made when prescribing PPIs, especially for esomeprazole and rabeprazole, as osteoporosis and fracture risks were increased in this cohort of elderly females subsequent to PPI prescription.