A 45-year-old man with chronic hepatitis B cirrhosis was referred to us for further outpatient care. When I reviewed him in my clinic, I noticed that he’s on esomeprazole. When asked why he was receiving this medication, the patient said it was first started since he was diagnosed as liver disease. He denied any history of upper gastrointestinal symptoms.
A 23-year-old woman with poorly controlled bronchial asthma on prednisolone was seen by my general internal medicine colleague at medical outpatient department. My curious colleague had found her on pantoprazole as well, despite no dyspeptic symptom.
A young patient with deep venous thrombosis was referred regarding the prophylaxis of peptic ulcer disease with warfarin. He’s otherwise with static haemoglobin level without dyspeptic symptom.
Do you find that the scenarios above are familiar in our clinical practice?
Proton pump inhibitors (PPIs), successors to the innovative H2 blockers, have revolutionized the treatment of gastro-esophageal reflux disease (GERD) and peptic ulcers, since their beginning of use in the early 1990s. Proton-pump inhibitors (PPIs) are a group of drugs whose main action is a pronounced and long-lasting reduction of stomach acid production. PPIs that are currently available in our local market are Omeprazole, Pantoprazole, Rabeprazole, Lansoprazole, Esomeprazole, and Dexlansoprazole. PPI is one of the commonest drug prescribed either inpatient or outpatient. Omeprazole is one of the top ranked drug of the forty most utilized drugs in the Malaysian clinical settings (Lim and Mohamed Izham, 2012). But, have we ever pay attention on reviewing our patients if the PPIs are really indicated? Do they really need long term PPIs?
One study in United States which involved 946 patients showed 36% was prescribed PPIs which had no documented indication and these caused around USD 233,000 in healthcare cost.1 A Singapore study, which involved 477 inpatients had demonstrated the overuse of PPIs that less than 50% of their patients were prescribed PPIs according to United States FDA guideline.2
There are growing concerns on overuse of PPIs in terms of side effect as well as healthcare cost. Long term PPIs are not without side effects. PPIs are reported to be associated with bone fractures (long term PPI reduces calcium absorption and thus decreases bone density), hospital acquired pneumonia, nutritional deficiencies or enteric infection (clostridium difficile). In 2011, the FDA had issued a safety warning regarding the risk of hypomagnesemia in those who take PPIs for more than a year. Moreover, there has been long debated about the usage of PPIs in the patients with cardiovascular disease. PPI users have been reported to have a higher risk of heart attack than those on other antacids. Furthermore, the use of PPIs may interfere with many other drugs sharing the same hepatic metabolic pathway involving cytochrome P450 enzymes.
There is a need for us to improve our standard in prescribing PPIs. Currently, we do not have our own clinical guideline of prescription of PPIs in Malaysia, except a statement published by Malaysian Society of Gastroenterology and Hepatology (MSGH) on the use of antiplatelet therapy and PPIs in the prevention of gastrointestinal bleeding in 2013.3 FDA guidelines could be applied in our clinical practice for the time being. And hopefully, a national consensus or guideline could be introduced in the new future to guide in prescription of PPIs.
| FDA accepted indications for the use of PPIs |
| Peptic ulcer disease
Erosive esophagitis Helicobacter pylori infection Gastro-esophageal reflux disease Pathological hypersecretory conditions Stress ulcer prophylaxis
|
| Other accepted or off labelled usage of PPIs as per FDA |
| Risk reduction of NSAID-associated peptic ulcer disease in patients on NSAIDs with >2 of the following risk factors :
– Age >65 years old – History of peptic ulcer disease or upper gastrointestinal tract bleeding – High dose NSAID therapy – Concomitant NSAID use with an anticoagulant, antiplatelet or glucocorticoid
Esophageal stricture (peptic) Barret’s esophagus To improve pancreatic enzyme absorbtion in cystic fibrosis Uninvestigated dyspepsia (short term trial, investigation required, if persistent) |
As a doctor, we need more judicious usage of PPIs. Education of medical staff is a critically important aspect in reducing PPI overutilization. PPIs are not the” SUPER” drug! Both the lifestyle and the dietary advice are still essential in the management of lots of digestive disorders. Step down approach could be an option in managing the patients who have achieved improvement of the symptom. And always bear in mind that most of the patients do not need “LONG TERM OR EVEN LIFELONG” PPIs! We should involve our Pharmacists as well, in which they can play a unique role ensuring that all medications are not only safe and efficacious, but also appropriate.
PPIs are available either on prescription or over the counter in Malaysia. As a consumer or a patient, if buying over the counter, you should check with your family doctor first – especially if you are on other medications or have other medical illness. And remember that they shouldn’t be taken for long term, unless prescribed by your doctors.
References:
- Heidelbaugh JJ, Goldberg KL, Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. AM J Manag Care. 2010;16:e228-234
- Christopher Tze Wei Chia, Wan Peng Lim, Charles Kien Fong Vu. Inappropriate use of proton pump inhibitors in a local setting. Singapore Med J. 2014;55:363-366
- Huck-Joo Tan, Sanjiv Mahadeva, Jayaram Menon, et al. Statements of the Malaysian Society of Gastroenterology & Hepatology and the National Heart Association of Malaysia task force 2012 working party on the use of antiplatelet therapy and proton pump inhibitors in the prevention of gastrointestinal bleeding. Journal of Digestive Diseases 2013; 14; 1–10.
By Dr Chieng Jin Yu, Medical Lecturer, Consultant Gastroenterologist and Hepatologist, Universiti Putra Malaysia (UPM).
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]