Proton pump inhibitors: too much of a good thing?

National Prescribing Service Limited ACN 082 034 393

An independent, Australian organisation for Quality Use of Medicines

Proton pump inhibitors: too much of a good thing?

ISSN 1441-7421 April 2004

Step-down for gastro-oesophageal reflux disease

Drugs for acid-related disorders contribute more to the costa of the PBS than almost any other group of drugs.1 The cost of prescribing of this group, which consists predominantly of the proton pump inhibitors (PPIs), is rising: in 2003, it was $534 million, an increase of 14% over the previous year. Do current levels of prescribing reflect judicious use of this class?

The ‘step-down’ approach is now recommended by most guidelines for people with gastro-oesophageal reflux disease (GORD).2–4 This strategy of using an initial 4–8 week course of standard-dose PPI rapidly controls symptoms and heals oesophagitis. Treatment can then be ‘stepped down’ to the minimum dose that maintains symptom control.

A potential problem with the step-down approach is that if the success of the initial treatment course and the need for ongoing PPI therapy are not reviewed, patients may continue to take unnecessarily high doses of PPIs. People known to have severe or complicated oesophagitis should continue with daily PPIs. For others, options for step-down include the following.

Low-dose maintenance therapy with PPIs

Most studies have found that a low-dose PPI prevents relapse in 70–80% of people with healed oesophagitis over 12 months.5–9 However, lower strength PPIs make up less than 10% of total PPI prescribing.10 Intermittent, symptom-driven use of PPIs Most people with endoscopy-negative GORD can satisfactorily control symptoms using this strategy11–13; on average, people take tablets every 2–3 days.12–14

Step-off PPIs

The Gastroenterological Society of Australia suggests ceasing PPIs after initial therapy except for people known to have severe oesophagitis.2 Most people will relapse and require re-treatment, but some can manage their symptoms with lifestyle modifications and antacids and/or histamine-2 receptor (H2) antagonists.

http://www.nps.org.au/__data/assets/pdf_file/0016/15820/news33_PPIs_0404.pdf