Proton pump inhibitors: too much of a good thing?

Proton pump inhibitors (PPIs) are a mainstay in the management of acid peptic disorders; they are highly effective at relieving symptoms and are generally well tolerated. However, there is growing international concern about their increasing use. Long-term use is only recommended in specific clinical situations, yet data indicate that this accounts for the majority of total use and large numbers of PPI users do not actually have a clear indication for therapy (http://www.nps.org.au/publications/health-professional/medicinewise-news/2015/proton-pump-inhibitors).

A big problem is that once people are on a PPI, therapy is often not stepped down appropriately. Up to 30% of patients may be able to stop PPI therapy after the initial course of therapy without experiencing symptoms, but a step-down approach is not necessarily part of their ongoing management. Overuse of PPIs may increase risks of adverse effects and incur unnecessary costs for both taxpayers and individuals.

While PPIs are generally considered safe, there are reports (mostly from observational studies) about more serious, albeit rare, adverse events associated with their use, including enteric infections, pneumonia, fractures and acute interstitial nephritis. While reports are insufficient to establish a causal relationship, they may warrant consideration, especially against a backdrop of significant overprescribing of PPIs.

In the past decade, at least two PPIs have featured annually in the top 10 most prescribed Pharmaceutical Benefits Scheme (PBS)-subsidised medicines and, in the 2013–14 financial year, over 19 million prescriptions were issued, most of these for managing gastro-oesophageal reflux disease. The most commonly prescribed PPI in 2013–14 incurred a cost of over $200 million to the PBS.

NPS MedicineWise has recently published a suite of free resources (http://www.nps.org.au/heartburn-and-reflux) to support quality use of PPIs, including a symptomatic management pad for use with patients, and a clinical e-audit and interactive online case study (Continuing Professional Development points available).