PPIs in Australia: used for too long at too high a dose

Patterns of PPI use in Australia between 2013 and 2016 confirm the need for PBS restrictions such as those introduced last year especially around use of higher doses and the number of allowed repeats.

Dispensing data from about 4.4 million people who received at least one PPI during the study period, showed that most people remained on the dose they initiated on.

Most people (78%) received a standard strength PPI (20-30 mg) however the data suggested high strength PPIs such as 40 mg esomeprazole were overused (17%) and low strength PPIs (10-15 mg) were underused (5%).

The study found the median duration of therapy was well beyond the guideline-recommended 4-12 weeks for most indications.

The median duration of all PPI therapy was 501 days for individuals continuing on maintenance therapy.

Overall, only 37% of all long-term treated people stepped down to a lower strength PPI at any time following initiation. Most of the step-down treatment was from high strength to standard strength esomeprazole.

The study also noted that people using PPIs over the long term were typically older and more likely to have also been dispensed an NSAID or anticoagulant than the whole group initiating on a PPI.

“The high proportion of longer-term PPI treatment with concomitant NSAIDs or anticoagulants suggests that they may be frequently prescribed for prevention rather than treatment,” the study said.

Yet the evidence for use of PPIs with NSAIDs was generated in high risk patients who had previously had GI bleeding.

“It has been noted in many other settings that ‘preventative’ use of PPIs with these medicines is a major driver of excessive long-term use.”

The study, led by UNSW’s Centre for Big Data Research in Health, noted a limitation that they did not have access to information on the indications for treatment.

Nevertheless, they concluded many people were likely being overtreated in duration and dose strength.

“Our study shows that the proportion of people continuing PPIs beyond the guideline-recommended maximum of 12 weeks is greater than that which might be expected to have conditions indicated for longer-term PPI treatment.”

“Around one third of people continuing on longer-term treatment step-down treatment to a lower strength PPI, however, most individuals do not deviate from their initiation strength.”

“In light of this, prescribers may wish to consider the strength prescribed at initiation, as well as routine medicine reviews to ensure long-term treatment is indeed indicated.”

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