Introduction

Proton pump inhibitors (PPIs) are commonly prescribed drugs in preventing and treating certain conditions for definite time periods. However, evidence suggests an association of wide range of adverse effects with unwarranted and incongruous sustained PPI use. Discrepancies in prescribing PPIs appears to revolve around physician attitudes and self-justified perceptions. This survey was conducted to evaluate the knowledge and perceptions of PPI‐related adverse events among physicians, and subsequent change in behaviour associated with the use of PPIs.

Aims & Methods

This was a prospective, questionnaire-based, multicentric survey with data collected from physicians across India who have volunteered to participate in periodic surveys.

Results

The survey was completed by a total of 465 physicians. The survey comprised of questions, with multiple choice answers, about general familiarity with concern about possible PPI adverse effects, awareness and beliefs about adverse effects, when to continue and deprescribe PPI. The physicians were also questioned regarding the extent to which they changed their prescribing habits as a result of studies of adverse effects. A significant proportion of physicians were unaware of the specific adverse effects with PPI use. Most were slightly concerned about adverse effects when prescribing PPIs; nearly 48% physicians somewhat changed their prescribing practices for PPIs on account of these adverse effects. More than half (55%) survey responders perceived the PPI to be moderately effective at reducing the risk of upper gastrointestinal bleeding, whereas 26% believed it was slightly effective, 17% as very effective, while 2% felt it was not effective at all.

Table: Respondent’s familiarity on adverse effects with PPI use

Conclusion

There is a need for strategies to alter behaviour based on a physicians’ awareness of NSAID risks, indications for PPIs, besides prescribing approaches in hospitals. Healthcare practitioners could benefit from explicit guidance about scenarios in which patients can safely discontinue the use of PPIs, and regarding strategies for de-escalation that are most likely to succeed. There should be a strong foundation for prescribing PPIs, and a balanced regime to be followed for only as long as essential, at the lowest effective dose avoiding avertible prescriptions.

Introduction

Proton pump inhibitors (PPIs) are commonly prescribed for acid-related disorders, yet concerns about overuse and long-term adverse effects persist. Physicians, due to their medical knowledge and unrestricted access to medications, may demonstrate unique self-medication behaviors. This study aimed to assess the prevalence, indications, self-prescribing habits, and awareness of PPI-related risks among physicians.

Aims & Methods

A cross-sectional online survey was administered to 442 physicians across different healthcare levels. The anonymous questionnaire collected data on demographics, frequency and indications for PPI use, self-medication practices, knowledge of adverse effects, and deprescribing behavior. Descriptive and comparative statistical analyses were conducted.

Results

Of the respondents, 60.8% reported occasional PPI use, and 52.0% admitted to self-medicating without prior medical consultation. The most common indications were gastroesophageal reflux disease (GERD) and dyspepsia. Preventive use (e.g., before fatty meals or alcohol) was rare, reported by only 6.1%. Although awareness of potential side effects was high, just 2.0% had discontinued or reduced PPI use due to adverse effects.

Conclusion

Self-medication and occasional PPI use are prevalent among physicians, despite a high level of awareness regarding potential harms. These findings underscore the need for targeted educational efforts and clearer deprescribing guidelines to promote more rational PPI use in the medical community.

Disclosure

The authors declare no conflicts of interest related to this study.

Introduction

Inappropriate proton pump inhibitor (PPI) use is a growing concern, with estimates of up to 70% of long-term use lacking a valid indication (1,2).

Aims & Methods

This study investigates the feasibility of PPI deprescribing in a primary care setting and evaluates its impact on gastrointestinal symptoms and blood values. General practitioners (GPs) recruited long-term, chronic PPI users without strict indication. Demographics, PPI duration/dosage, medical history, and GP-estimated success probability were registered at baseline (Visit 0). Patients on healing-dose PPIs at baseline were down-titrated to maintenance dose for 1 month before deprescription at Visit 1. At Visit 1, all patients were instructed to deprescribe their PPI within one month. After this period, patients returned for Visit 2, where the PPI was stopped completely if feasible. One month later, during Visit 3, patients entered a one-year follow-up period. Patients returned after 6 and 12 months for Visit 4 and 5, respectively, with online questionnaires at 3 and 9 months. Gastrointestinal symptoms (nausea, fullness, bloating, upper abdominal pain, lower abdominal pain, heartburn) were assessed using the PAGI-SYM questionnaire. Successful deprescription was defined as ≤3 PPI doses/month. Optional blood samples at baseline and end of study measured gastrin, magnesium, calcium, iron, and vitamin B12 levels. Results are shown as median(IQR).

Results

Sixty GPs included a total of 640 patients (62(50-70) years, 60% female, BMI 27(25-31) kg/m²). Down-titration from healing to maintenance dose (n=128) before PPI deprescription was successful in 92% of the patients.
One month after deprescribing, 76% of patients (n=444/582) had successfully interrupted their PPI intake. Of these, 78% maintained success, resulting in a sustained success rate of 61% (n=264/432). Success rates did not differ by initial PPI indication (dyspepsia, low-grade GERD, NERD, non-gastric indications), demographics or initial PPI dose. However, GP-estimated success probability at baseline was associated with successful deprescribing at 6 months (p=0.0075, OR = 2.6, 95%CI: 1.3–5.2).
Patients who successfully reduced PPI intake reported a transient increase in heartburn (p<0.0001) after deprescribing (visit1), returning to baseline during follow-up. Interestingly, bloating and postprandial fullness decreased significantly during follow-up (visits 2-4) compared to baseline (both p<0.0001).
A significant difference in delta magnesium (+0.01 vs -0.03 mmol/l, p=0.004) and gastrin levels (-57 vs. -19 pg/mL, p=0.002 ) was observed between successfully (n=105) and unsuccessfully (n=41) deprescribed patients.

Conclusion

PPI deprescription is highly feasible in primary care, with a sustained success rate of 61% after 6 months. While heartburn may transiently increase, bloating and postprandial fullness improved. In patients who successfully reduced PPI intake. Magnesium levels increased while gastrin levels decreased.

References

1. Boghossian TA et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017 Mar 16;3(3).
2. Heidelbaugh JJ, Kim AH, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012;5(4):219–32.

Disclosure

All authors have declared no conflict of interest.

Introduction

Increasing concerns arise regarding inappropriate proton pump inhibitor (PPI) use in terms of indication and dosage, impacting healthcare budgets and posing possible risks and drug interactions. It was estimated that up to 70% of PPI use may not medically indicated, however, the characteristics of this population of patients have not been described (1,2).

Aims & Methods

We aim to describe demographic and clinical profiles of primary care PPI users who lack a strict medical indication.
General practitioners included long-term PPI users without strict medical indication in the study. Demographic characteristics, duration and dosage of PPI use, and medical history (e.g. upper endoscopy findings, H. pylori status and previous attempts to stop PPI) were registered. Patients completed questionnaires assessing gastrointestinal symptoms (PAGI-SYM) and psychosocial co-morbidities (depression, somatization, and anxiety using respectively PHQ-9, PHQ-15, GAD-7). For this analysis, patients were categorized by: (I) initial indication for PPI therapy (GERD with low-grade esophagitis, dyspepsia, non-gastric symptoms) and (II) PPI dose (healing or maintenance). Statistical significance (p<0.05) was assessed using one-way ANOVA, student’s T-test, and Fisher’s exact test. Results are shown as mean±SD.

Results

Out of 482 recruited patients on long-term PPI therapy, 42% reported failed previous attempts to discontinue PPI therapy. Main indications for PPI initiation were low-grade reflux esophagitis (26%), functional dyspepsia (18%), uninvestigated reflux symptoms (13%), uninvestigated dyspepsia (10%), peptic ulcer (2%) and mixed causes (18%, e.g. polymedication, cough, hoarseness,….). A history of H. pylori infection was present in 9% of patients. Patients exhibited on average low somatization, no depression, and no anxiety (Table).
There were no differences in age and sex among cohorts on healing (n= 80, 62% female, mean age 61 ± 13 y.o.) or maintenance PPI dose (n=362, 58% female, mean age 61 ± 14 y.o.). However, those on healing doses had a significantly higher BMI (29.2 ± 4.9 vs 27.6 ± 4.4 kg/m², p=0.003) and reported higher scores on all PAGI-SYM subscales (NS), with a significantly higher score on the postprandial fullness & early satiety subscale (average score of 1.4 ± 1.3 vs. 1.1 ±1.0, p=0.030). There were no significant differences in psychosocial co-morbidities between patients on healing or maintenance PPI doses (all p>0.05).
Sex, age, and BMI were similar among subgroups based on the initial reason for PPI therapy. Patients in whom PPI therapy was initiated for dyspepsia had significantly higher bloating scores than those with reflux or non-gastric symptoms (p=0.011). Furthermore, dyspepsia patients exhibited significantly higher somatisation (p=0.015), depression (p=0.007), and anxiety (p=0.002) compared to reflux symptom patients.

Conclusion

A large subset of patients with prolonged PPI intake lacking a strict medical indication have unsuccessfully attempted to stop PPI usage. The patients who are long-term on healing doses have a significantly higher BMI and more severe postprandial distress syndrome symptoms. Psychosocial co-morbidity is significantly higher in patients in whom PPIs were started for dyspeptic symptoms. These characteristics are relevant when considering attempts to deprescribe PPIs in primary care.

References

1. Boghossian TA, Rashid FJ, Thompson W, Welch V, Moayyedi P, Rojas-Fernandez C, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017 Mar 16;3(3).
2. Consensusvergadering – Het rationeel gebruik van de protonpompinhibitoren (PPI’s) bij nietulcereuze gastro-oesofageale pathologie. RIZIV. 2018; Available from: www.riziv.fgov.be

Introduction

Proton pump inhibitors (PPIs) are one of the most frequently prescribed drugs with high risk of the over-prescription.

Aims & Methods

Objective: to find potential sources of the over-prescription by analysis of prescription policy and its evolution in time by means of descriptive statistics
Methods: Analysis from the National Registry of Reimbursed Health Services (2010-2022) was performed targeting reimbursed prescription of ATC group A02BC (PPIs) and A02BA (H2 receptor blockers) with respect to the age of patient and prescribing specialist.

Results

More than 300 million defined daily doses (DDD) of antisecretory drugs were prescribed in 2022; PPIs represent the vast majority (296.2 million, 99 %). This volume rose 2.6 times during the 13 years span, the speed of rise is slowing but still 2.4 % yearly.
PPI were prescribed to 1.314 million of patients in 2022 and this number also rose 1.5 times for 13 years. 48 % of PPI users in 2022 were seniors over 65 years, majority of patients treated by PPIs was in 7th decade of life (24 %), while it was 6th decade till 2018 - age of patients rose in the observed period. PPI was prescribed to more than 12 % of the overall population in 2022, but to 29 % of senior population over 65 years of age!
Vast majority of PPI prescription (in DDD) is realized by general practitioners (GP, 67.8 %). The highest proportion of non-GP prescription (95.5 million DDDs) is realized by: gastroenterology (26.9 %), internal medicine (19.2 %), cardiology (9 %), rheumatology (6.1 %) and ENT (ears-nose-throat, 5.4 %). While overall PPI prescription (in DDD) rose 2.6 times during the last 13 years; higher increment was reached by ENT (18.7 times), allergology/immunology (5.7 times), pneumology (4.4 times); cardiology (4 times) and rheumatology (3.1 times).

Conclusion

Global volume of PPI prescription is overwhelming and covers almost a third of senior population. The rise during 13 years was 2.6 times in DDD and 1.5 times in the number of patients; and probably approaches the plateau. GPs are responsible for longstanding maintenance prescription and realize more than 2/3 of the volume. Prescription by specialist probably mirrors rather introductions of prescription. Prophylactic co-prescription with antithrombotic agents and NSAIDs can be responsible for increase in cardiology and rheumatology. Excessive increase of prescription in ENT (and to less extent pneumology and allergology/immunology) is probably to the account of extraesophageal reflux (EER). Routine long-term prescription of PPI for EER (which has no unequivocal diagnostic criteria so far) is a matter of debate because profit was proven dominantly in patients with simultaneous “classical” gastroesophageal reflux symptoms (1,2). EER can be a target population for de-prescribing strategies.

References

1. Krause AJ. Review article: diagnosis and management of laryngopharyngeal reflux. Aliment Pharmacol Ther. 2024;00:1-16.
2. Raghu G. Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults. An official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Resp Crit Care Medicine 2022;9:e18-e47.

Introduction

The use of proton pump inhibitors (PPIs) has increased in many Western countries over the past decades. This may reflect the increasing prevalence of symptoms of gastroesophageal reflux disease (GERD) and prophylactic PPI use against gastroduodenal ulcers and haemorrhage induced by non-steroid anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid. However, increasing PPI use against functional or uninvestigated dyspepsia and other inappropriate prescription have previously been documented and may also have contributed to the observed increase in PPI use. In this study we describe the change in incident and prevalent PPI use over time and the indication for prescription.

Aims & Methods

Nationwide data were retrieved from the Norwegian Prescription Database (NorPD) and consisted of information about dispensed prescription drugs. The study population consisted of all adults with at least one PPI prescription during the study period from 2009 to 2022. PPIs were defined by their ATC codes A02BC01 – C05 in addition to M01AE52, which is an esomeprazole and naproxen combination product. Prevalent PPI use was defined as the period covered by the defined daily doses (DDD) in each prescription. The indications for prescription were defined by ICPC or ICD-10 codes depending on whether PPI was prescribed in primary care or secondary health care. National data from the Norwegian Patient Registry (NPR) on all upper endoscopies performed during the study period were combined with NorPD data and it was assessed whether incident PPI users, defined as no PPI dispensal for two years, had undergone an upper endoscopy 180 days before or after incident PPI use.

Results

The use of PPI increased from 58.1 mill DDD in 2009 to 166.9 mill DDD in 2022, i.e. 15700 DDD/1000 and 38700 DDD/1000 persons. The absolute increase in DDDs was driven by a 3.5-fold increase in esomeprazole and a 5-fold increase in the use of pantoprazole.
The prevalence of PPI use increased from 3.5% in 2009 to 9.9% in 2022. The incidence of PPI use increased from 2.85% in 2011 to 5.42% in 2022.
In 2009 the dominant indications in primary and secondary health care, respectively, were esophageal disease and GERD (72.5% and 10.7% of DDDs), gastric ulcer (3.3% and 0.46% of DDDs), duodenal ulcer (0.86% and 0.21% of DDDs), while prescriptions with no reimbursement diagnosis constituted 10.2% of DDDs. In 2022 the dominant indications were esophageal disease and GERD (57.6% and 4.7% of DDDs), musculoskeletal disorders and pain (7.1% and 0.39% of DDDs and in combination with naproxen), prophylaxis against gastroduodenal ulcer (4.8% and 0.95% DDDs), while prescriptions with no reimbursement diagnosis constituted 5.2% of the DDDs.
There were 2.27 mill cases of incident PPI use in the study period and the proportion of PPI users that underwent upper endoscopy around treatment start decreased from 25.3% in 2009 to 11.1% in 2022. In patients with esophageal disease or GERD combined the proportion examined by upper endoscopy fell from 41.4% to 27.1%, while in patients without a reimbursement diagnosis the proportion fell from 19.2% to 6.9%.

Conclusion

In this nationwide study a 2.8-fold increase in prevalent PPI use was observed during the 14-year study period. This was caused by an absolute increase in PPI use against esophageal disease and GERD as well as prophylaxis in patients given ulcerogenic comedication. The proportion of incident PPI use investigated by upper endoscopy was halved.

Introduction

Proton pump inhibitors (PPIs) are widely prescribed open-ended fashion, but in an estimated 25-82% of patients this may be inappropriate.[1, 2] Chronic PPI use is associated with an increased risk of specific adverse events including pneumonia, dementia, and osteoporotic fractures although no causal relationships have been established.[3] However, recent surveys have found that among physicians who regularly prescribe PPIs, a considerable proportion were unfamiliar with deprescribing strategies.[2] Here, we assessed whether an 30-minute online independent medical education activity could improve primary care physicians’ (PCPs) and gastroenterologists’ knowledge, confidence and competence regarding the long-term management of reflux and PPI deprescribing.

Aims & Methods

Educational effect was assessed using a repeated-pairs design with pre-/post-assessment. Three multiple choice questions assessed knowledge, and one question assessed confidence. Statistical tests to assess significance included: Paired samples t-test for overall average number of correct responses and confidence. McNemar’s test for individual questions and learning objectives (P <.05). Cohen’s d estimated the effect size impact on number of correct responses (<.20 modest, .20-.49 small, .59-.79 moderate, ≥.80 large).

Results

From a total of 3422, there were 359 assessment completers. Overall, there were highly significant and impactful knowledge gains for both groups of physicians (PCPs P <.001, Cohen's d = 0.87; Gastroenterologists P <.001, Cohen's d = 1.02). For PCPs, the highest relative proportional change in knowledge was for the extent of PPI overuse and misuse at 161% with 38% of physicians improving their knowledge (P<.001). Whilst for gastroenterologists the highest relative proportional change was seen regarding the implications of PPI overuse at 277% with 37% of physicians improving knowledge following the activity (P<.001). Significant increases in physician competence in best practice in PPI deprescribing were found (P<.001 for both), despite high baseline levels of competence. A considerable proportion of PCPs (51%; confidence shift 69%; P <.001) and gastroenterologists (39%; confidence shift 52%; P <.001) increased their confidence regarding their ability to use appropriate management strategies to reduce or discontinue a patient's use of PPI therapy.

Conclusion

Online medical education significantly improved physicians’ knowledge, confidence and competence regarding the extent and implications of PPI overuse and best practice in the long-term management of reflux and PPI deprescribing. As PPI prescribing is prevalent and long-term use is common, it is important that physicians understand appropriate indications and implications associated with over and long-term use and are also able to undertake clinically appropriate deprescribing approaches.

References

1. Kurlander, J.E., et al., Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study. Bmj, 2024. 385: p. e076484.
2. Piñerúa-Gonsálvez, J.F., et al., BEHIND THE PROTON PUMP INHIBITOR PRESCRIPTION: AN INTERNATIONAL SURVEY ON PHYSICIAN PRACTICES AND KNOWLEDGE. Arq Gastroenterol, 2024. 61: p. e23153.
3. Vaezi, M.F., Y.X. Yang, and C.W. Howden, Complications of Proton Pump Inhibitor Therapy. Gastroenterology, 2017. 153(1): p. 35-48.