Overuse of proton pump inhibitors

Background: There have been concerns raised about the potential adverse eff ects of proton pump inhibitors, especially with long-term use. In particula r, their potent action can suppress the features and delay the diagnosis of gastric cancer, while prolonged exposure may hasten the development of gas tric carcinoids. Aim: To examine the use of proton pump inhibitors in patients at the major teaching hospital in Tasmania, Australia, principally to determine the appr opriateness of the therapy according to published guidelines. Methods: A retrospective review of the medical records of all patients pres cribed any of the proton pump inhibitors at the hospital over a 7-month per iod, was performed. An extensive range of demographic and clinical variable s was recorded for each patient. The patients were also asked a series of q uestions during their hospitalization to extract some of the relevant infor mation - in particular, if and when they had undergone endoscopy. Results: 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 gas trointestinal bleeding (20.9%), severe refractory ulcerating oesophagitis ( 17.3%), mild/moderate oesophageal reflux (17.3%) and refractory peptic ulce r (11.7%). A large number of patients were using a proton pump inhibitor fo r 'other' indications (39.6%). The prescribing of proton pump inhibitors sa tisfied the approved indications, as outlined in the Australian Schedule of Pharmaceutical Benefits, in only 37.1% of cases. Endoscopy had been perfor med in 54.1% of patients prior to commencing therapy with a proton pump inh ibitor and within the next 7 days in another 12.8% of patients. Only 59% of patients had previously been treated with an H-2-receptor antagonist befor e commencing therapy with a proton pump inhibitor. Even worse, only 58.5% o f patients had used an Ha-receptor antagonist before a proton pump inhibito r for mild/moderate oesophagitis. The median duration of proton pump inhibi tor therapy for patients admitted to the hospital and already receiving one of the drugs was 450 days. Over half of the patients were being concurrent ly treated with other drugs which are known to cause or exacerbate gastro-o esophageal disease, and 18% were smokers. Conclusions: Whereas the proton pump inhibitors are undoubtedly effective a gents, studies of their prescribing in practice consistently suggest overus e prior to endoscopy, use in patients who do not fit the approved criteria, and prescribing for indications in which 'less powerful' agents should hav e been sufficiently effective for the patient's symptoms. This poses econom ic and safety concerns, particularly in light of the suggestion that these drugs could delay the diagnosis of gastric cancer.