Mohammed A Alzahrani et al /JAASP 2016;1:341-45

RESEARCH PAPER

The Prescribing Pattern of Proton Pump Inhibitors

by Non-gastroenterologists in a Tertiary Teaching
Hospital in the Kingdom of Saudi Arabia

Mohammed A Alzahrani1, Basma A Al Ghamdi2 , Hana S Al ahmari2 , Eman Ali

Alqahtani2, Ameen G Saleh2, Mohammed Elbagir K Ahmed1*
1
King Khalid University, Abha, Saudi Arabia
2
Aseer central hospital , Abha, Saudi Arabia

Keywords Abstract
Proton Pump Inhibitors Proton pump inhibitors (PPIs) are widely prescribed classes of
Prescribing medications. Their superior acid suppression lead to its use for the
Hospital treatment of gastroesophageal reflux disease, helicobacter
eradication, and other gastrointestinal problems. However, irrational
Correspondence use outside the approved indications is observed in some settings. The
Mohammed Elbagir K
objective is to study the prescription pattern of PPI outside the
Ahmed
Assistant professor and
gastroenterology service and whether this conforms to the best
medical consultant – King practice guidelines. This was a retrospective descriptive cross
Khalid University, Abha, sectional study in Aseer central hospital, a tertiary teaching hospital in
Saudi Arabia Abha, Saudi Arabia over a 2-month period. The charts of all new
patients who were prescribed PPI outside the gastroenterology service
E-mail were reviewed. Descriptive statistics were used for analysis. The study
mohamedelbagir@live.com included 114 (71 females, 94% Saudis) with mean age of 51.8 (SD 22
years. Range: 13 to 96 years.) The frequencies of prescriptions in
different disciplines showed that Cardiovascular disorders (acute
coronary syndromes, atrial fibrillation and heart failure) had the
highest frequency (37 patients) followed by the neurology division (13
patients with stroke.), respiratory disorders: 12 (pneumonia &
COPD), and trauma.(12 patients) Co-administered drugs such as
aspirin, clopidogrel, and warfarin were observed in over 40 patients..
The IV route was used in 74 out of the 114 (65%), out of whom 46
patients were able to take orally. Outside the gastrointestinal service,
PPIs were irrationally used, sometimes without a guideline support.
The IV route was unnecessarily used in the majority of
patients.Doctors should abide by the guidelines when they prescribe
PPIs.

Introduction irreversibly inhibits the activity of the proton

pump, resulting in an increase of gastric pH.
Proton pump inhibitors (PPIs) are widely This class of medications has revolutionized the
prescribed classes of medications that are used way in which clinicians manage acid-related
in the treatment of multiple gastrointestinal disorders of the GI tract. They have become
(GI) disorders. They exert their effect by the standard treatment of gastroesophageal
inhibiting the H+/K+-adenosine triphosphatase reflux disease (GERD), peptic ulcer disease
(ATPase), or proton pump, which is located in (PUD), and helicobacter eradication, the most
the highly acidic lumen of parietal cells (H commonly encountered conditions resulting in
Blume et al., 2006). This highly acidic upper GI complaints (Malfertheiner P et all.,
environment enables the PPI to become 2013). The use of these agents has increased
protonated to its active metabolite which then by 456% since the 1990’s (Eid, A et al., 2010)

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RESEARCH PAPER

As a result; these drugs have become one of diseases like peptic ulcer disease,
the world’s most frequently prescribed gastroesophageal reflux disease,
medications. Several clinical trials have gastrointestinal bleeding, and helicobacter
demonstrated that proton pump inhibitors are associated dyspepsia. In addition, patients
both safe and well tolerated when used with incomplete details were also excluded.
appropriately (Malfertheiner P et al., 2013). Descriptive statistics were used for analysis.
However, PI’s overuse and accompanying
misuse increases the likelihood of adverse Results and Discussion
effects. Because most gastric-acid related The study included 114 patients (71 females,)
disorders require long-term treatment, the risk with mean age of 51.8 (SD 22 years, range:
for clinically significant adverse drug 14 to 96 years.)
interactions is probable in patients who are The frequencies of prescriptions in different
receiving other medications in conjunction with disciplines were as follows: (Table 1):
a PPI. Several reports have suggested that  Cardiovascular disorders: 37 (acute
PPIs are being overused in hospital and coronary syndromes, atrial fibrillation
ambulatory care settings and that the and heart failure).
appropriateness of PPI prescriptions in some  Neurological problems: 13 patients
hospitals is as low as 19% (M Naunton et al., with stroke.
2000).  Respiratory disorders: 12 (pneumonia
The incidence of improper use of PPIs varies & COPD),
from 40-70% in various studies. Initiation and  Trauma: 12,
the continuous use of these drugs without  Rheumatology: 10 ( Rheumatoid
correct indications will result in significant cost arthritis and , SLE),
to the patient. Proton pump inhibitors should  ICU: 10 (critically ill patients),
be used more judiciously and awareness  General surgery 10 patients,
 Others: DM, 4 (DKA). Infectious
should be created among the clinicians in the
diseases: 4 (sepsis), renal diseases: 2
hospital so that appropriate prescription of
(renal failure).
PPIs will improve the patient care at low cost
(L Pasina et al., 2010), (Nousheen et al., Table 1: Proton Pump Inhibitors Prescriptions
2014). by different disciplines

The objective of the present study was to

explore the use of these drugs outside the GI Discipline Number %
service and find out whether this conforms to
Cardiovascular 37 32
best practice guidelines in a teaching hospital
Neurology 13 11.3
in Abha, Saudi Arabia, since there is Pulmonary 12 10.5
presumptive evidence that the PPI are
Trauma 12 10.5
overused by non-gastroenterologists (Joel J et
al., 2010) ICU 10 9
Rheumatology 10 9
General Surgery 10 9
Methods Endocrine 4 3.5
This was a retrospective descriptive cross Infectious diseases 4 3.5
Renal 2 1.7
sectional study performed in Aseer central
hospital, a 700 bed tertiary teaching hospital in
Co-administered drugs: 39 patients were given
Abha, Saudi Arabia which serves a population
aspirin with or without clopidogrel, while 29
of about 500,000. The study was performed
patients were using warfarin. The overall rate
over a 2month period as from September
of inappropriate use was 72%. The main
2013. The charts of all new patients who were
reason for this was the lack of a valid
prescribed PPI outside the gastroenterology
indication. Others reasons for
service were reviewed by three of the authors
inappropriateness included the failure to
(BA, HA, &EA). Core information such as
indicate the right dose and duration of therapy.
demographic factors, diagnosis, the attending
The IV route was used in 74 out of the 114
physician, and medications were recorded.
(65%), out of whom 46 patients were able to
According to the objective of the study, we did
take orally. Pantoprazole was the commonest
not include patients who were already taking
prescribed PPI through the IV route. Others
PPIs or patients with definite gastrointestinal

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RESEARCH PAPER

included omeprazole (18 patients), and route will increase the total estimated direct
esomeprazole for 8 patients. cost (drug acquisition cost) as shown in a
study from Saudi Arabia which revealed that
This study showed that, outside the the cost of IV PPI was very high and that
gastrointestinal service, there was a high rate inappropriate IV PPI utilization was
of inappropriate use of PPIs, particularly so in predominant in non-ICU patients, mostly for
the cardiovascular discipline. The possible stress ulcer prophylaxis that leads to a waste
interactions between antithrombotic drugs and of resources (Alsultan MS 2010).
proton pump inhibitors resulting in reduced Overall, PPIs are considered over utilised when
antithrombotic effect and increased prescribed without an appropriate indication
cardiovascular risk for patients receiving and when patients are left on them
combination therapy has been suggested in 'indefinitely' (Bhatt DL, 2012). Moreover,
previous studies (Mette Charlot et al., 2011). further studies found that inappropriate
Particular attention has been given to the prescribing of PPIs without documented valid
interaction between clopidogrel and proton indications to be prevalent among elderly
pump inhibitors, but an interaction between patients in Singapore, providing further
aspirin and proton pump inhibitors has also evidence that shows a similar trend to PPI
been proposed ( Heidelbaugh JJ, 2010) (Bhatt prescribing data from Western countries
DL , 2012). Another area of inappropriate use (Farooq A, 2016).
was observed in patients admitted with
pneumonia who received a PPI. A previous Thus, multiple variables should be taken into
meta-analysis study demonstrated that the account before prescribing a proton pump
PPIs use was associated with increased inhibitor including: dosages, duration of
prevalence of community acquired pneumonia, therapy and clinical reasons for the use of a
thus such patients should not receive PPIs PPI, accompanied by an assessment of the
without a solid indication (Giuliano C, 2012). appropriateness of the treatment (Boparai V,
Also, the present study documented 2008).
prophylactic use of PPIs in the ICU and trauma Also, the economic impact of overprescribing
units to prevent stress and NSAIDS induced PPIs should be taken in consideration. A
gastritis based upon guideline previous study showed that between 25% and
recommendations that stressed that ulcer 70% of patients who took these drugs long
prophylaxis should be administered to all term did not have an appropriate indication
critically ill patients who are at high risk for (Forgacs I, 2008).
gastrointestinal (GI) bleeding, although
disagreement about which clinical Another retrospective review of 946 patients
characteristics define high risk exists. conducted in an ambulatory care setting found
Moreover, the Surviving Sepsis Campaign only 35% of the patients were given PPIs for
guidelines recommend the use of PPIs rather an appropriately documented upper
than H2RBs for stress ulcer prophylaxis citing gastrointestinal tract diagnosis, whereas the
level 2C evidence (Dellinger RP, 2013) ( remaining patients were given PPIs for either
Alhazzani W, 2013) Furthermore, the post- extraesophageal symptoms, unclear
operative use of PPIs is generally not gastroprotection, or no documented
recommended unless there is a clear appropriate indication (Heidelbaugh JJ, 2010).
indication. As well, using PPIs for diabetic
patients with complications such as Conclusion
ketoacidosis is not justified without a clear
indication.
The strong evidence supporting PPI efficacy
and a favorable safety profile may have
This study also revealed that the IV route was contributed to significant overprescription.
injudiously used in most patients, the majority Physicians should abide by the published
of whom were able to take by mouth. practice guidelines (Such as the Saudi drug
Approved indications of intravenous (IV.) formulary, the Saudi gastroenerology
proton pump inhibition (PPI) are limited to association guidelines, and other international
acute gastrointestinal bleeding, treatment of guidelines) when prescribing PPIs so as to
reflux oesophagitis, in patients unable to avoid patient harm and wasting of resources
tolerate oral medications, and for patients with (Forgacs I, 2008), (Heidelbaugh J, 2012).
pathologic hypersecretory states.14
Furthermore, such inappropriate use of the IV

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Obviously our study has some limitations, in coronary artery disease. N Engl J
mainly the retrospective nature of the study Med 2010;363:1909–1917.
and the fact that it was conducted only among
inpatients users. Heidelbaugh JJ, Metz DC and Yang YX. Proton
pump inhibitors: are they overutilised
in clinical practice and do they pose
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