The rational prescription of medications is vital to ensuring the optimal use of medical resources, providing effective therapy and minimizing adverse drug reactions. In practice, a few of the most common irrational uses of medicines are excessive prescriptions of antibiotics, proton pump inhibitors (PPIs) and glucocorticoids [1,2,3]. Since omeprazole, the first PPI, emerged in the market in the late 1980s, PPIs have proven to be an effective therapeutic option in a variety of acid-related disorders including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori eradication therapy, dyspepsia and stress ulcer prophylaxis. The use of PPIs increased by 450% in the 1990s relative to earlier years . There is a growing number of publications on the overuse of PPIs in clinical practice worldwide. For example, in the United States, PPIs were prescribed in 4% of outpatient visits in 2002 and 9.2% in 2009 . A Spanish drug-utilization study showed that 28.65% of inpatients were prescribed a PPI on admission, 82.62% during hospitalization, and 54.75% at discharge; moreover, incorrect indications for PPIs were found in 74.47, 61.25 and 80.24% of these cases, respectively . Furthermore, previous studies showed that once PPIs were started in the hospital, more than 50% of patients continued to take them 3 to 6 months after discharge, even in the absence of an indication [7,8,9]. The uncontrolled overutilization of PPIs resulted in the number of prescriptions for PPIs ranking 8th on the list of the top therapeutic classes by prescriptions in 2013. Meanwhile, PPIs are one of the highest-selling classes of drugs in many countries. The expenditure on PPIs is $14 billion (United States), £425 million (England), and £7 billion a year (globally), and almost £100 million in England and £2 billion worldwide are being spent unnecessarily on PPIs each year [10, 11]. More recently, research has uncovered similar phenomena regarding PPI overuse in China. A drug-utilization study showed that 35.59% of inpatients were prescribed PPIs . Two other studies found that 30.95 and 76.3% of surgical patients received stress ulcer prophylaxis (SUP) with PPIs, but the majority of them (59.26 and 67.03%, respectively) had received this medication without indications and for long durations [13, 14], which was linked to economic waste. A few factors postulated to contribute to the overutilization of PPIs include the high incidence of acid-related disease, the high efficacy and relatively low toxicity profile of PPIs, the acceptable costs of treatment with both generic and originator preparations, their availability as over-the-counter drugs and consumer-oriented advertising. However, prior studies have demonstrated that PPIs are associated with pneumonia, enteric infection, osteoporosis, hypomagnesemia and drug-drug interactions [15,16,17,18]. Therefore, to prevent these complications and avoid medical waste, it is essential to implement interventions to improve the rational use of PPIs, especially for prophylactic applications.
In recent years, various measures have been taken by authorities in China to control the irrational use of medicines and to reduce patients’ medical expenditure, especially for medicines. First, “Prescription Management Measures” and “Rules for the management of the hospital’s prescription review (trial)” were established to standardize doctors’ prescription behavior and promote the rational use of drugs. Second, the catalogues of National Essential Medicine and National Medical Insurance were published by the National Health and Family Planning Commission and the Ministry of Human Resources and Social Security of the People’s Republic of China, respectively. Moreover, the National Health and Family Planning Commission dictated that pharmaceutical expenditure in public hospitals must account for less than 30% of their total incomes, while the costs of essential medicine and originator drugs must account for more than 25% or less than 20% of total pharmaceutical expenditure. Consequently, the drugs in the two catalogues and generics should be preferred. However, pharmaceutical expenditures in hospitals actually account for approximately 40 to 50% of their total income. Finally, a real-time clinical pharmacist intervention program was implemented, which could promote the rational use of antibiotics and PPIs, resulting in favorable economic outcomes [19, 20].
There are six PPIs (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole and ilaprazole) available as both oral enteric-coated tablets and intravenous injections and as both generics and originators in China. These drugs are all listed in the national medical insurance catalogue, except for ilaprazole. However, only one of the six PPIs, omeprazole, is listed in the catalogue of national essential medicine. Generic PPIs are available at a lower cost than originators, and oral PPIs are similar in effectiveness to injectable PPIs at equivalent doses. Nevertheless, previous studies found considerable use of injectable and originator PPIs. In addition, PPI overuse was usually the result of inappropriate SUP in non-intensive care patients. Therefore, to promote the rational prophylactic use of PPIs and improve the prevention of stress ulcers, the “Consensus Review for SUP and Treatment” and “Prevention and Treatment of Stress Related Mucosal Disease” were published in 2015 in China . PPIs were under the supervision of Health and Family Planning Commission of Sichuan Province as one of the overused groups as of February 2, 2016. Several supervision measures were formulated including a clinical pharmacist intervention. The work role of clinical pharmacists was to correct doctors’ misunderstanding, monitor medical records in real time and control the prescriptions of PPIs based on the criteria established by the hospital administration.
The primary objective of the study was to report the trends in PPI utilization and expenditure in a tertiary teaching hospital over the past decade. The secondary objective was to evaluate the impact of clinical pharmacist interventions and certain management policies for the rational use of PPIs.