Long-Term Use of Proton Pump Inhibitors in Primary Care Patients
Long-Term Use of Proton Pump Inhibitors in Primary Care Patients
Background The use of proton pump inhibitors (PPIs) is extensive. While the incidence of new treatments remains stable, the prevalence of long-term treatment is rising. Studies have shown that up to 70% of patients on chronic acid suppression lack a verified indication for treatment.
Aims To investigate primary care patient characteristics associated with long-term use of PPIs.
Methods A cross-sectional analysis of 42 634 patients registered with 22 general practitioners was performed. Patients with prescriptions of ≥120 tablets/year were defined as long-term users. A survey of a subgroup of patients without verified indication was performed.
Results In all, 901 (2.1%) patients were long-term treated. Verified indications for treatment were identified for 247/901 (27%). An upper GI endoscopy had been performed in 418 patients (46%). Of the 194/654 without verified indication who participated in the survey, 71% reported heartburn/acid regurgitation as the reason for therapy. On-demand therapy was reported by 43/194 (22%) and previous attempts to withdraw by 119/194 (61%).
Conclusions The prevalence of PPI long-term treatment among primary care patients is 2.1%. The main reason for treatment is reflux symptoms or verified GERD. Rationalization of use of PPIs is possible as daily treatment without attempts to discontinue is frequently observed.
The use of proton pump inhibitors (PPIs) for acid-related symptoms and disorders is extensive and continuously escalating. While the incidence of new treatments with PPIs remains stable, the prevalence of long-term treatment is rising. Treatment with PPIs is initiated mainly by primary care physicians (PCPs) as empirical therapy of reflux or dyspeptic symptoms. This approach is supported by dyspepsia guidelines, which recommend treatment for 4 weeks or longer in patients with uninvestigated symptoms.
Long-term treatment with a PPI is indicated in patients with erosive oesophagitis (EO) or other complications of gastro-oesophageal disease (GERD), in patients with persistent symptoms of endoscopy-negative gastro-oesophageal reflux disease (ENRD) and as prophylactic therapy for patients with a previously documented NSAID-induced peptic ulcer, who need continuous NSAID therapy. Previous studies have shown that up to 70% of patients on chronic acid suppression lack an endoscopically verified indication for long-term treatment. However, the proportion of patients treated long-term because of symptomatic (i.e. non-endoscopy verified) reflux disease has not been studied. As this is now a generally accepted indication for treatment, the proportion of patients without an approved diagnosis for long-term treatment is unknown.
Furthermore, it is known that a substantial proportion of patients with GERD can be managed adequately with PPI treatment on demand. How many patients treated long-term because of ENRD or uninvestigated reflux symptoms who use PPI therapy on demand is not fully known. It is recommended that patients treated long-term with a PPI are evaluated regularly to attempt withdrawal or stepping down of therapy. It is unknown if patients without a verified indication continue therapy without intervention or if withdrawal is attempted.
The aim of this study was to investigate primary care patient characteristics associated with long-term use of PPIs according to indications for treatment. Furthermore, we aimed at clarifying self-reported effect, management strategies and previous discontinuation of long-term PPI treatment in patients without verified indication.
Abstract and Introduction
Abstract
Background The use of proton pump inhibitors (PPIs) is extensive. While the incidence of new treatments remains stable, the prevalence of long-term treatment is rising. Studies have shown that up to 70% of patients on chronic acid suppression lack a verified indication for treatment.
Aims To investigate primary care patient characteristics associated with long-term use of PPIs.
Methods A cross-sectional analysis of 42 634 patients registered with 22 general practitioners was performed. Patients with prescriptions of ≥120 tablets/year were defined as long-term users. A survey of a subgroup of patients without verified indication was performed.
Results In all, 901 (2.1%) patients were long-term treated. Verified indications for treatment were identified for 247/901 (27%). An upper GI endoscopy had been performed in 418 patients (46%). Of the 194/654 without verified indication who participated in the survey, 71% reported heartburn/acid regurgitation as the reason for therapy. On-demand therapy was reported by 43/194 (22%) and previous attempts to withdraw by 119/194 (61%).
Conclusions The prevalence of PPI long-term treatment among primary care patients is 2.1%. The main reason for treatment is reflux symptoms or verified GERD. Rationalization of use of PPIs is possible as daily treatment without attempts to discontinue is frequently observed.
Introduction
The use of proton pump inhibitors (PPIs) for acid-related symptoms and disorders is extensive and continuously escalating. While the incidence of new treatments with PPIs remains stable, the prevalence of long-term treatment is rising. Treatment with PPIs is initiated mainly by primary care physicians (PCPs) as empirical therapy of reflux or dyspeptic symptoms. This approach is supported by dyspepsia guidelines, which recommend treatment for 4 weeks or longer in patients with uninvestigated symptoms.
Long-term treatment with a PPI is indicated in patients with erosive oesophagitis (EO) or other complications of gastro-oesophageal disease (GERD), in patients with persistent symptoms of endoscopy-negative gastro-oesophageal reflux disease (ENRD) and as prophylactic therapy for patients with a previously documented NSAID-induced peptic ulcer, who need continuous NSAID therapy. Previous studies have shown that up to 70% of patients on chronic acid suppression lack an endoscopically verified indication for long-term treatment. However, the proportion of patients treated long-term because of symptomatic (i.e. non-endoscopy verified) reflux disease has not been studied. As this is now a generally accepted indication for treatment, the proportion of patients without an approved diagnosis for long-term treatment is unknown.
Furthermore, it is known that a substantial proportion of patients with GERD can be managed adequately with PPI treatment on demand. How many patients treated long-term because of ENRD or uninvestigated reflux symptoms who use PPI therapy on demand is not fully known. It is recommended that patients treated long-term with a PPI are evaluated regularly to attempt withdrawal or stepping down of therapy. It is unknown if patients without a verified indication continue therapy without intervention or if withdrawal is attempted.
The aim of this study was to investigate primary care patient characteristics associated with long-term use of PPIs according to indications for treatment. Furthermore, we aimed at clarifying self-reported effect, management strategies and previous discontinuation of long-term PPI treatment in patients without verified indication.