Until the late 20th century, acid–peptic disorders such as gastro-oesophageal reflux disease (GORD) condemned those affected to a lifetime of ineffective dietary restrictions and antacids.4 Complications from these disorders were a persistent problem in gastroenterology,5 the only effective long-term treatment being surgery.6 The discovery of gastric-acid suppressing medicines – H2-receptor antagonists and proton pump inhibitors (PPIs) – marked a change. Although both classes of medicines provide symptom relief in GORD, PPIs are significantly more effective than H2 antagonists at relieving symptoms and healing oesophagitis.7,8
While highly effective with a favourable safety profile, use of PPIs is not without concern. Since their introduction in the early 90s, PPI use has increased by more than 1000% in Australia,2 with over 19 million prescriptions in the 2013–14 financial year.1 Over the last decade, at least two PPIs have featured in the top 10 most prescribed PBS-subsidised medicines every year.1,9 Not surprisingly, there is growing international concern over their increasing use.2,10 Long-term use is only recommended in selected populations11,12 but data indicate that this accounts for most of the total use.10 Several studies suggest that a substantial proportion of PPI users do not have a clear indication for therapy (Table 1).13-18
Some reports have linked PPI use to increased risk of fractures, pneumonia, enteric infections, vitamin and mineral deficiencies, and acute interstitial nephritis.5,19 Although the absolute risk is very low, many of the patients in these reports were older people – a group that makes up the largest proportion of PPI users 2 and who are at increased risk of medicine-related problems.20 While there is insufficient evidence to establish causation, these reports deserve consideration.
There are also financial implications of overuse, with extensive costs to both individuals and government. In the 2013–14 financial year, there were close to 7 million PBS-subsidised prescriptions for esomeprazole in Australia, at a cost of over $200 million to the PBS.1
While PPIs remain a mainstay of management of acid–peptic disorders, the concerns about adverse effects and cost associated with over-prescribing highlight the need for increased attention to their judicious use.