Typically, a step-down procedure or PRN therapy was recommended after counsel with the patient. A significant portion of the people presenting with GORD were found to have positive results with a stepped-down regiment after a 2-3 week period of daily higher dose consumption to control initial symptoms. If the patient had day-time distress they were advised to take medication a half-hour before breakfast and if symptoms arose at night, the medication was to be taken a half hour before dinner. Follow-up was recommended after a period of 4-8 weeks to evaluate a possible increase or step down in treatment.
If any alarm symptoms such as dysphasia, nocturnal choking or melaena were reported the therapy was stopped immediately. This did not happen during the course of the audit. In the case of Mr. Lee, life-long treatment will probably be necessary due to the reoccurrence of his symptoms after cessation of omeprazole, although he should have been reevaluated after only 4-6 weeks. Elimination of symptoms after continuing the medication confirms the effectiveness of treatment. However, Mr. Lee was not tested for H. Pylori as this may be a cause of gastrointestinal distress and since this is permanently treatable may be an easier solution.
Generally, patients are recommended to undergo an endoscopy and if necessary, be tested for the existence of H. Pylori. This leaves PPI’s as a last resort, but since they are a relatively harmless medication they are safe for the general population, as long as the minimum dosage is utilized. The use of PPI’s are a necessary tool in the treatment of quality of life issues such as GORD and peptic ulcers. They are effective and safe alternatives to Histamine H2- receptors, or long term solutions to antacids in the inhibition of gastric acid secretion.
However, their use by the population at large must be monitored by those most easily to do so, the pharmacists prescribing them. It has been well documented that a change in diet is remarkably effective in reducing the effects of acid secretion and thereby treat gastric and duodenal ulcers. Unfortunately, it is many times easier for a patient to treat the symptoms of the disease than it is to change their lifestyle. Therefore, the minimum dosage must be arrived at via a series of follow-up visits and many times a symptom-based prescription regiment may actually be effective in the relief of distress.
Mr. Lee in case study 57 is an example of a gentleman that may need permanent PPI use. His symptoms are indicative of an underlying cause that is not easily relieved with simple changes in diet. His fears of possible long term renal damage are not unfounded, but the possibility of this occurring is rare. Just like with any patient, alarm symptoms need to be monitored to assure safe usage. In the end, it is the role of the pharmacist to ensure the safe and proper dispersal of medication. Even a benign medication such as PPI’s can be harmful if given to a large population over a long period of time.
PPI’s are found to be one of the safer drugs on the market so their use is not as worrisome as some others but it is precisely this reason that pharmacists must be vigilant in the use of all prescriptions. Complacency concerning prescriptions can be detrimental no matter what medication is given. References 1. Dr. Andrew Beveridge, Dr. Geoffrey Hebbard. (2007). Case Study 57 report: Proton Pump inhibitors- appropriate and safe use. National Prescribing Service Limited. 1 (1), 1-20. 2. Dr. John Marley. (1997). Proton pump inhibitors. Australian Prescriber. 20 (1), 16. 3. Yeomans, Dr, Neville. (2000).
Drugs that inhibit acid secretion. Australian Prescriber. 23 (1), 57-59. 4. Smallwood, Dr. Richard. (1995). The management of acid peptic disease. Australian Prescriber. 18 (1), 97-99. 5. National Prescribing Service Limited. (2003). Pharmacy practice review: a counselling and action resource. 1 (1), 1-15. 6. Worthley,Daniel L. ; Fraser,Robert J.. (2005). Management of acute bleeding in the upper gastrointestinal tract . Australian Prescriber. 1 (1), 1-3. 7. Badov, David; Lambert, John. (1997). Testing for Helicobactor pylori . Australian Prescriber. 1 (1), 1-3.