Overprescribing, functional dyspepsia and PPWhy’s?

Sometimes (often), it feels like us GP's can't do anything right.

Whether that’s not seeing everyone in the whole world within two weeks, or hiding behind a telephone, now we’re also being told we’re vastly overprescribing our trusty friend the proton pump inhibitor (PPI), including long term for functional dyspepsia. 

So where does this latest charge come from, is it justified, and what should we be doing differently? What’s more, am I the only who’s not entirely sure what function dyspepsia actually is? Luckily, new research from the BJGP and long overdue guidance from the British Society of Gastroenterology are here to shed some light.

PPIs are some of the most commonly prescribed drugs, with nearly 60 million prescriptions dispensed annually in the UK alone. Their usage has doubled since 2007 so, it’s true, we do seem to be prescribing them more and more. Furthermore, they’re perhaps not the benign wonder drugs we once thought and have been associated with a variety of adverse effects, including clostridium difficile colitis, osteoporosis and kidney disease.

The most recent headline generating paper is a primary care observational study from Netherlands, published this month in the BJGP. The authors evaluated the appropriateness of PPI prescriptions issued by Dutch GPs to a population of nearly 150,000 patients over a three-year period. 

The headline messages were:

• 16% of all patients were prescribed a new PPI over the study period
• For more than half of patients (56%), these were deemed ‘inappropriate’ prescriptions. 
• Even when the script was appropriate, the PPIs were then often continued unnecessarily.
  • 32% of patients on short course therapy for dyspepsia continued this inappropriately. 
  • 11% of patients taking a PPI for ulcer prophylaxis continued even after the drug which initiated the PPI prophylaxis was stopped. 
• Inappropriate prescribing was associated with increasing age, perhaps reflecting that clinicians may be more likely to prescribe ulcer prophylaxis to frail older patients, irrespective of a valid indication. 

So what should we be doing differently? The authors of the paper have a few sensible sounding suggestions. 

1. Reduce PPI use for unnecessary ulcer prophylaxis - can we avoid that ‘just in case’ PPI prescription, for example when we prescribe an NSAID in a low risk patient? 
2. Timely de-prescription when a PPI is no longer needed. 
   • Explicitly inform patients when commencing treatment that the PPI is for a limited time.
   • Ensure adequate follow up and structured medication review (ideally from our practice pharmacist), including checking when PPIs are prescribed by our secondary care colleagues
   • Be aware of rebound symptoms which can complicate discontinuation - again, patient awareness is probably key here.
3. Be able to suggest alternative therapies for functional dyspepsia to patients. 

But, what is functional dyspepsia and what exactly are those alternatives I should be suggesting?

Think of it as like ‘IBS of the stomach’, and thankfully after 25 years and a whole lot of research, the British Society of Gastroenterology has produced new and updated guidance on its management. This is really important as up to 80% of our patients with dyspepsia are thought to have this syndrome. We cover this interesting new guidance, and the implications for us and our patients, on our current round of Hot Topics courses.

In the meantime this new research remind us that whilst PPIs are important and effective drugs when appropriately prescribed, over-prescribing is common. This can over medicalize patients, expose them to risk and gives us a lot more work in managing their repeat prescriptions. De-prescribing always feels good and asking yourself PPWhy? when prescribing is good start.