Many patients may be being treated with these expensive drugs without having tried life-style modification or simpler, less expensive treatments. Stopping smoking, reducing fat in the diet and alcohol intake, as well as weight loss for those patients who are overweight, should be tried first (see also 'The management of acid peptic disease' Aust Prescr 1995;18:97-9). Taking a proton pump inhibitor may allow patients to continue an unhealthy life-style which may be bad for their heart as well as their heartburn.

The long-term safety of profound acid inhibition is unknown. Carcinogenesis is a long latency adverse reaction to drugs. Who knows if the bending of clinicians to aggressive drug promotion, and the resultant prescribing, is not setting in place a drug disaster which will not become apparent for many years.

The cost of reimbursing the supply of proton pump inhibitors has risen from $79.5m to $130m in one financial year. Authority data show that 86% of proton pump inhibitor use is for severe erosive ulcerating oesophagitis, 79.5% of prescriptions being written by general practitioners. Is there an epidemic of this condition in Australia at present? Undoubtedly, the introduction of these drugs has revolutionised the quality of life for patients who have this disease. However, in how many patients are these drugs honestly necessary, with the diagnosis reliably established - especially given the poor correlation between symptoms and diagnostic tests such as endoscopy and oesophageal pH monitoring?

As prescribers, we need to remember the opportunity cost - if so much money is spent on these drugs, it is not available to be spent in other areas of medicine. Choices and rationing are part of health care in every country today.

John Marley

Professor, Department of General Practice, University of Adelaide, Royal Adelaide Hospital, Adelaide