Proton Pump Inhibitor (PPI) prescribing: Changing the conversation between patients and clinicians
Rhys Howell, Mark Andrews, Leanne Griffin, Timothy Asibey-Berko, Rob Bevan, Gautham Appanna, and Keir Lewis
ABMU Health Board, Hywel Dda UHB, Cardiff University and Swansea University
Bevan Commission Academy Fellows
Some patients benefit from a Proton Pump Inhibitor (PPI) either in the short or long term. However, for many PPI use is unnecessary, may cause harm and mask the symptoms of an unhealthy lifestyle. The conversation between patients and clinicians needs to change in line with the following prudent healthcare principles:
Prudent Principle 1
Achieve health and well-being with the public, patients and professionals and as equal partners through co-production.
Initial discussions highlighted a variety of reasons for prescribing. GPs cited the commonest indication as gastro-oesophageal reflux disease, whereas hospital consultant use was related to their speciality e.g. steroid prophylaxis.
Patients seem largely unaware of potential long term risks or alternative strategies. GPs reported a mixed response in discussions with patients regarding cessation of PPI therapy.
Prudent Principle 2
Care for those with the greatest health need first, making most effective use of all skills and resources.
Could changing conversations between clinicians and patients around PPI use result in more prudent prescribing?
More than 10% of people in Wales take a PPI, with use increasing. Suggested reasons for this include unhealthy lifestyle, medication culture and lack of alternative management plans (e.g. step down, use of antacids to manage rebound acid hypersecretion etc).
Prudent Principle 3
Do only what is needed, no more, no less and do no harm.
What strategies might be employed to halt or reduce the rise?
Evidence is building regarding adverse effects associated with long term PPI use including potential consequences such as increased risks of enteric infections e.g. C.difficile; pneumonia, fractures, hypomagnesaemia and vitamin B12 deficiency.
Prudent Principle 4
Reduce inappropriate variation using evidence based practices consistently and transparently.
How might we ensure such information is used to support prudent prescribing and reduce harm?
Impacts and future actions
How can we use this information and other approaches to reduce variation?
- Explore public and prescriber views to identify reasons behind the continuous increase and local variations in PPI prescribing and opportunities for engagement and intervention.
- Engage with others in developing interventions e.g. to inform patient and prescribers including:
- Benefit/risk assessment of PPI therapy for individual patients.
- Prescription review with step down/cessation as appropriate.
- Support to make lifestyle choices to alleviate reflux symptoms.