1
|
Mari A, Marabotto E, Ribolsi M, Zingone F, Barberio B, Savarino V, Savarino EV. Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future. Expert Rev Clin Pharmacol 2023; 16:913-923. [PMID: 37632213 DOI: 10.1080/17512433.2023.2252327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 08/27/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged. AREAS COVERED In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future. EXPERT OPINION PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.
Collapse
Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Nazareth, Israel
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Rome, Italy
| | - Fabiana Zingone
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, ItalyI
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| |
Collapse
|
2
|
Sattayalertyanyong O, Thitilertdecha P, Auesomwang C. The inappropriate use of proton pump inhibitors during admission and after discharge: a prospective cross-sectional study. Int J Clin Pharm 2019; 42:174-183. [PMID: 31865594 DOI: 10.1007/s11096-019-00955-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/13/2019] [Indexed: 12/11/2022]
Abstract
Background Proton pump inhibitors are often inappropriately prescribed during hospital admission and after discharge. The inappropriate prescription may be associated with increased and unnecessary healthcare costs. Objective To determine the prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge at Thailand's largest national tertiary referral center. Setting Medicine wards at Siriraj Hospital (Bangkok, Thailand) during September 2016 to September 2017. Method This prospective observational cross-sectional study in hospitalized patients who were prescribed, or who were already taking proton pump inhibitors. Medical records were reviewed to determine whether proton pump inhibitors were prescribed at discharge and at the 1-month follow-up. Main outcome measure Prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge, indication of inappropriate prescription. Results Two hundred and sixty-five patients (mean age: 65.8 ± 18.3 years, 50.9% men) were included. Approximately half of patients had proton pump inhibitor treatment initiated in the hospital, and the other 50.6% started treatment earlier. Among all patients, 50.6% were inappropriately prescribed proton pump inhibitors, in which 79.1% resulted from invalid indications. Fifty-two percent and 47.3% of patients who were prescribed proton pump inhibitors at discharge and at the 1-month follow-up had no indications for them. Gastrointestinal ulcer prophylaxis in low-risk patients was the most commonly observed incorrect indication. Aspirin (p = 0.030) and corticosteroids (p = 0.038) were both found to be significantly associated with the inappropriate prescription of proton pump inhibitors. The estimated cost of inappropriate use among inpatients and outpatients was $118,659 and $214,663 per year, respectively. Conclusion Proton pump inhibitors are excessively and inappropriately prescribed during hospital admission and after discharge in Thailand. The cost of this overprescribing is excessive and needs to be controlled.
Collapse
Affiliation(s)
- Onuma Sattayalertyanyong
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Premrutai Thitilertdecha
- Research Group in Immunobiology and Therapeutic Sciences, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chonticha Auesomwang
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| |
Collapse
|
3
|
Savarino V, Marabotto E, Zentilin P, Furnari M, Bodini G, De Maria C, Pellegatta G, Coppo C, Savarino E. Proton pump inhibitors: use and misuse in the clinical setting. Expert Rev Clin Pharmacol 2018; 11:1123-1134. [PMID: 30295105 DOI: 10.1080/17512433.2018.1531703] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The introduction of proton pump inhibitors (PPIs) into clinical practice has greatly improved our therapeutic approach to acid-related diseases for their efficacy and safety. Areas Covered: The following evidence-based indications for PPI use are acknowledged by many scientific societies: treatment of the various forms and complications of gastroesophageal reflux disease, eradication of H. pylori infection in combination with two or more antibiotics, short- and long-term therapy of H. pylori-negative peptic ulcers, healing, and prevention of NSAID/COXIB-associated gastric ulcers, co-therapy with endoscopic procedures to control upper digestive bleeding and medical treatment of Zollinger Ellison syndrome. Expert Commentary: Despite the above well-defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and the endless expansion of the PPI market has created important problems for many regulatory authorities for two relevant features: the progressive increase of the costs of therapy and the greater potential harms for the patients. The major reasons for the misuse of PPIs are the prevention of gastro-duodenal ulcers in patients without risk factors and the stress ulcer prophylaxis in non-intensive care units, steroid therapy alone, anti-platelet or anti-coagulant treatment in patients without risk of gastric injury and the overtreatment of functional dyspepsia.
Collapse
Affiliation(s)
- Vincenzo Savarino
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Elisa Marabotto
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Patrizia Zentilin
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Manuele Furnari
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Costanza De Maria
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Gaia Pellegatta
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Claudia Coppo
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Edoardo Savarino
- b Gastrointestinal Unit, Department of Surgery , Oncology and Gastroenterology, University of Padua , Padua , Italy
| |
Collapse
|
4
|
Savarino V, Marabotto E, Zentilin P, Furnari M, Bodini G, De Maria C, Pellegatta G, Coppo C, Savarino E. The appropriate use of proton-pump inhibitors. Minerva Med 2018; 109. [DOI: 10.23736/s0026-4806.18.05705-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
5
|
Savarino V, Tosetti C, Benedetto E, Compare D, Nardone G. Appropriateness in prescribing PPIs: A position paper of the Italian Society of Gastroenterology (SIGE) - Study section "Digestive Diseases in Primary Care". Dig Liver Dis 2018; 50:894-902. [PMID: 30093304 DOI: 10.1016/j.dld.2018.07.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/04/2018] [Accepted: 07/09/2018] [Indexed: 02/06/2023]
Abstract
The introduction of proton pump inhibitors (PPIs) into clinical practice about thirty years ago has greatly improved our therapeutic approach to acid-related diseases for their well-recognized efficacy and safety. Despite the well-defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and this phenomenon poses serious queries that include the onset of potential adverse effects and the increase in health care costs. The major reason explaining this worrying market expansion is the inappropriate use of PPIs. In order to re-establish a correct use of these effective drugs in daily clinical practice, the Italian Society of Gastroenterology (SIGE), nominated a panel of experts who reviewed the available clinical literature and produced a series of updated position statements on the use of PPIs in clinical practice.
Collapse
Affiliation(s)
| | | | | | - Debora Compare
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Italy
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Italy.
| |
Collapse
|
6
|
Guarnotta V, Martini C, Davì MV, Pizza G, Colao A, Faggiano A. The Zollinger-Ellison syndrome: is there a role for somatostatin analogues in the treatment of the gastrinoma? Endocrine 2018; 60:15-27. [PMID: 29019150 DOI: 10.1007/s12020-017-1420-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/02/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Analyze the role of somatostatin analogues (SSAs) in the treatment of sporadic and MEN1-related gastrinomas, trying to define whether recent trials have changed the landscape of gastrinoma therapy. METHODS We evaluate the rationale of SSA use in the treatment of gastrinomas, summarize the current literature concerning the effect of SSAs on the control of Zollinger-Ellison syndrome (ZES) and gastrinomas tumor progression and discuss their role in the most recent guidelines. RESULTS The medical treatment of gastrinoma and related ZES is aimed at controlling acid hypersecretion and tumor progression, in inoperable patients. The use of proton pump inhibitors (PPIs) to control the syndrome is a cornerstone in the ZES therapy. SSAs are not usually indicated for antisecretory purpose, because PPIs are considered the treatment of choice, due to their long lasting high efficacy and oral availability. The antiproliferative effect of SSAs has been established by two placebo-controlled trials that have clearly demonstrated a significant increase in progression free survival in patients affected by non-functioning well-differentiated advanced neuroendocrine tumors (NETs). The recent ENETS guidelines recommend the use of SSAs in advanced well differentiated NETs as antiproliferative agents. CONCLUSIONS The high sstr-expression in gastrinomas make them highly responsive to SSAs and support the use of such drugs to counteract the tumour growth in patients not amenable to surgical cure. Unfortunately, limited data, mainly case reports or small series, support the use of SSAs in advanced gastrinomas, therefore, it is difficult to quantify their ability to control tumour growth and disease progression.
Collapse
Affiliation(s)
- Valentina Guarnotta
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Endocrine-Metabolic Diseases, University of Palermo, Palermo, Italy
| | - Chiara Martini
- Clinica Medica 3^, Department of Medicine, DIMED, University of Padova, Padova, Italy.
| | - Maria Vittoria Davì
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Verona, Italy
| | - Genoveffa Pizza
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Annamaria Colao
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Antongiulio Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione G. Pascale" - IRCCS, Naples, Italy
| |
Collapse
|
7
|
Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med 2016; 14:179. [PMID: 27825371 PMCID: PMC5101793 DOI: 10.1186/s12916-016-0718-z] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications. METHODS The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence. RESULTS Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile. CONCLUSIONS Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .
Collapse
Affiliation(s)
- Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy.
| | - Luigi Gatta
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy
- Gastroenterology & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Angelo Zullo
- Division of Gastroenterology & Digestive Endoscopy, Nuovo Regina Elena Hospital, Rome, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
8
|
Lodato F, Poluzzi E, Raschi E, Piccinni C, Koci A, Olivelli V, Napoli C, Corvalli G, Nalon E, De Ponti F, Zoli M. Appropriateness of Proton Pump Inhibitor (PPI) prescription in patients admitted to hospital: Attitudes of general practitioners and hospital physicians in Italy. Eur J Intern Med 2016; 30:31-36. [PMID: 26926561 DOI: 10.1016/j.ejim.2016.01.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Proton pump inhibitor (PPI) prescriptions have raised concern for both huge increase of health expenditure and possible long-term adverse effects. OBJECTIVE To evaluate appropriateness of PPI prescription in ambulatory and hospital care. DESIGN Observational cohort study. PATIENTS Patients admitted to the Internal Medicine Unit of Bologna S. Orsola Hospital between 15/09/2013 and 15/12/2013. Data on clinical condition and drug therapy were collected at three time points: admission (reflecting GP's prescription), hospital stay and discharge. MAIN MEASURES Appropriateness of PPI use was evaluated as follows: (1) agreement between PPI use/non-use and appropriate clinical condition; (2) in PPI users, assessment of Medication Appropriateness Index (MAI). Differences in appropriateness among time points were analyzed by chi-square test. Logistic regression model was used to identify possible determinants of PPI appropriateness. KEY RESULTS Among 280 patients, 56% received PPI at least once in the three time points. Appropriateness, according to indication of use, was similar between admission and hospital stay (61% vs. 62%; p=0.82) and between hospital stay and discharge (62% vs. 59%; p=0.94). MAI score showed important, although statistically non-significant, change in appropriateness between admission and hospital stay (20% vs. 28%; p=0.16). Age≥65 was always associated with appropriate PPI use (up to OR=4.37; p<0.01), whereas cardiovascular comorbidity and conditions requiring analgesic treatment influenced appropriateness only at admission (OR=3.84; p<0.01 and OR=0.34; p<0.01, respectively). CONCLUSIONS Hospital clinicians only rarely reconsidered GP's choice to prescribe PPI. Room for improvement in PPI appropriateness is represented by (1) assessing gastrointestinal risk in each patient under analgesics and anti-inflammatory drugs, and (2) short-term re-evaluation of PPI prescription after discharge.
Collapse
Affiliation(s)
- Francesca Lodato
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Carlo Piccinni
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Ariola Koci
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Valentina Olivelli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Chiara Napoli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Giulia Corvalli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Elena Nalon
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Marco Zoli
- Unit of Internal Medicine, S. Orsola-Malpighi Hospital and Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| |
Collapse
|
9
|
Banihani SA. Histamine-2 Receptor Antagonists and Semen Quality. Basic Clin Pharmacol Toxicol 2015; 118:9-13. [DOI: 10.1111/bcpt.12446] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/06/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Saleem A. Banihani
- Department of Medical Laboratory Sciences; Jordan University of Science and Technology; Irbid Jordan
| |
Collapse
|
10
|
Akram F, Huang Y, Lim V, Huggan PJ, Merchant RA. Proton pump inhibitors: Are we still prescribing them without valid indications? Australas Med J 2014; 7:465-70. [PMID: 25550719 DOI: 10.4066/amj.2014.2093] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia. AIMS We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore. METHOD We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as "valid", "likely invalid", and "probable" based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected. RESULTS From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as "likely invalid"); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was "probable". The most common "likely invalid" indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions. CONCLUSION Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.
Collapse
Affiliation(s)
- Farooq Akram
- University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore
| | - Yufang Huang
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Valencia Lim
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Paul J Huggan
- Waikato District Health Board, Hamilton, New Zealand
| | - Reshma A Merchant
- University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore
| |
Collapse
|
11
|
Abstract
INTRODUCTION The role of pharmacotherapy in the management of patients with Zollinger-Ellison syndrome (ZES) is often equated with the medical management of acid hypersecretion. However, pharmacotherapy is also increasingly involved in the other management areas of these patients. AREAS COVERED This paper reviews the role of pharmacotherapy in all aspects of the management of patients with ZES. Newer aspects are emphasized. This includes the difficulty of diagnosing ZES in patients taking proton pump inhibitors. Also covered is the role of pharmacotherapy in controlling acid hypersecretion and other hormonal hypersecretory states these patients may develop, including hyperparathyroidism in patients with multiple endocrine neoplasia type 1 and ZES; tumor localization; and the treatment of advanced metastatic disease. The last includes chemotherapy, liver-directed therapies, biotherapy (somatostatin/interferon), peptide radio-receptor therapy and molecular-targeted therapies including the use of mTor inhibitors (everolimus) and tyrosine kinase inhibitors (sunitinib). EXPERT OPINION Pharmacotherapy is now involved in all aspects of the management of patients with ZES, with the result that ZES has progressed from being considered an entirely surgical disease initially to the present where medical treatment plays a major role in almost all aspects of the management of these patients.
Collapse
Affiliation(s)
- Tetsuhide Ito
- Kyushu University, Graduate School of Medical Sciences, Department of Medicine and Bioregulatory Science, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | | | | | | |
Collapse
|
12
|
Ahrens D, Behrens G, Himmel W, Kochen MM, Chenot JF. Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care. Int J Clin Pract 2012; 66:767-773. [PMID: 22805269 DOI: 10.1111/j.1742-1241.2012.02973.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Inappropriate prescriptions of proton pump inhibitors (PPI) in hospital and primary care have been widely reported. Recommendations from hospital have been implicated as one reason for inappropriate prescriptions of PPI in primary care. Objective: To quantify the amount of appropriate PPI recommendations in hospital discharge letters and the influence of these recommendations on general practitioners' (GPs') PPI-prescriptions. Materials and Methods: This is an observational study in 31 primary care practices. We identified patients discharged from hospital with PPI recommendation between 2006 and 2007 and assessed practice records and PPI prescription six months prior and after hospital admission. Hospital recommendation for continuous PPI-treatment and continuation by GPs was classified as appropriate, inappropriate or uncertain. Logistic regression analysis was used to calculate factors associated with indicated and non-indicated PPI continuation. Results: In 263 (58%) out of 506 patients discharged from 35 hospitals with a PPI recommendation no indication could be found. Non-indicated PPIs were continued by GPs in 58% for at least 1 month. Indicated PPIs were discontinued in 33%. Two thirds of non-indicated PPIs were initiated in hospital. The strongest factor associated with non-indicated continuation was a PPI-prescription prior to hospital admission [OR: 3.0; 95% confidence interval (CI): 1.7-5.4]. This was also the strongest factor for continuation of an indicated PPI medication (OR: 3.2; 95% CI: 1.4-7.5). Conclusions: We found a strong influence of hospital recommendations and previous prescriptions on PPI prescriptions after discharge. Hospitals should critically review their practice of recommending PPI and document indications. GPs should carefully assess hospital recommendations and their medication prior to admission to avoid over- and under-prescribing.
Collapse
Affiliation(s)
- D Ahrens
- Department of Family Practice, Göttingen University Medical Center, Göttingen, Germany Department of Family Practice, University Medicine Greifswald, Institute for Community Medicine, Greifswald, Germany
| | | | | | | | | |
Collapse
|
13
|
Jensen RT, Cadiot G, Brandi ML, de Herder WW, Kaltsas G, Komminoth P, Scoazec JY, Salazar R, Sauvanet A, Kianmanesh R. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: functional pancreatic endocrine tumor syndromes. Neuroendocrinology 2012; 95:98-119. [PMID: 22261919 PMCID: PMC3701449 DOI: 10.1159/000335591] [Citation(s) in RCA: 340] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
14
|
Ahrens D, Chenot JF, Behrens G, Grimmsmann T, Kochen MM. Appropriateness of treatment recommendations for PPI in hospital discharge letters. Eur J Clin Pharmacol 2010; 66:1265-71. [PMID: 20694459 PMCID: PMC2982961 DOI: 10.1007/s00228-010-0871-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 07/10/2010] [Indexed: 12/18/2022]
Abstract
PURPOSE The reasons for the dramatic increase in proton pump inhibitors (PPI) prescriptions remain unclear and cannot be explained solely by increased morbidity, new indications or a decrease in alternative medication. Inappropriate use and discharge recommendations in hospitals are considered to be possible explanations. As the quality of PPI recommendations in hospital discharge letters in Germany has not been investigated to date, we have studied the appropriateness of these referrals. METHODS Hospital discharge letters with recommendations for PPI medication from 35 primary care practices in the county of Mecklenburg-Western Pomerania (MV; North-east Germany) were collected and analysed, and the appropriateness of the PPI indication was rated. RESULTS No information justifying the recommendation for continuous PPI medication could be identified in 54.5% of the discharge letters; in 12.7%, the indication was uncertain, and in 32.7%, we found an evidence-based indication for PPI medication. The most common indication for adequate PPI use was nonsteroidal anti-inflammatory drug-prophylaxis in high-risk patients. CONCLUSIONS Inadequate recommendations for PPIs in discharge letters are frequent. This may lead to a continuation of this therapy in primary care, thereby unnecessarily increasing polypharmacy and the risk of adverse events as well as burdening the public health budget. Hospitals should therefore critically review recommendations for PPI medication and the dosage thereof in their discharge letters and clearly document the reason for PPI use and the need for continuous prescription in primary care.
Collapse
Affiliation(s)
- Dirk Ahrens
- Department of General Practice, University of Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Jean-François Chenot
- Department of General Practice, University of Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Gesa Behrens
- Department of General Practice, University of Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Thomas Grimmsmann
- Medical Review Board of the Statutory Health Insurance Funds Mecklenburg-Vorpommern, Schwerin, Germany
| | - Michael M. Kochen
- Department of General Practice, University of Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| |
Collapse
|