PPI’s are largely prescribed for quality of life issues such as Gastro esophageal Reflux Disease (GORD), dyspepsia, oesophagitis or peptic ulcers, most of which can be treated with lifestyle changes more effectively than with long-term PPI prescription (pharmacy review, 200). It is the role of the pharmacist to determine via established tools the proper course of action in treating a patient dealing with common issues that can be solved with PPI’s. In many instances long-term use of PPI’s is a necessary and cost effective method of treatment.
However, rare but possible serious side effects such as C. difficile infection, PPI-induced interstitial nephritis or blood dyscrasias can occur and must be considered when long-term treatment is considered (Beveridge, 17). In this instance, case study 57 is considered for possible continuing prescription of PPI. After a review of his background and previous regiment the patient, Mr. Lee, was evaluated and prescribed a continuous prescription of the PPI omeprazole for symptom control of his GORD.
It is the duty of the pharmacist in this scenario to evaluate the patient for possible alternative treatments and if none are available to prescribe the smallest dosage possible that will be effective. PPI’s have an extraordinary track record for safety. Adverse side effects are mild if they exist at all. Serious side effects are rare but include several serious adverse effects as stated above. In the larger context of the population, these rare side effects may become harmful when the amount of people given PPI prescriptions is considered.
Therefore, it is up to the pharmacist to evaluate patients regularly to determine the level of medicine required for proper symptom control. Numerous other drugs are on the market that may be more suitable for GORD or any of the other symptoms patients present with. Symptom based antacid use, for example, is an over-the-counter alternative to long-term treatment with PPI’s (Smallwood et al, 2010). Alternative drugs may cause their own side effects that can, and are, more detrimental than PPI treatment.
As always, lifestyle changes need to be stressed upon by the patient, especially the pharmacist. In the instance of Mr. Lee in case study 57 very few studies have been shown to draw a link between weight, smoking or alcohol and GORD, so it is likely that despite his weight issues, smoking and drinking his problems will continue. Healthier living, however, is always a recommendation the pharmacist can give to improve other aspects of the patient’s life. PPI’s are a drug that can be easily over prescribed.
While there may be millions in the country that actually do require GORD treatment with the drug, the underlying cause needs to be established before a long term prescription is given. The general patient that presents with GORD or related symptoms is overweight, has a poor diet and often drinks socially 2-3 times a week. Of these habits, poor diet has been shown to have the greatest effect on GORD. Convincing the patient to change their lifestyle has been difficult to say the least, with many preferring to simply treat the symptoms rather than fix the root cause.
In any event, consistent repetition of the more effective possibility of a change in diet is necessary when dealing with patients. Having said this, there is a large portion of the population that has genuine disorders such as duodenal or gastric ulcers that are easily treatable with PPI’s. Their use, though, must be minimized or eliminated altogether so as to reduce the risk of serious adverse effects. As stated by others, “The long-term safety of profound acid inhibition is unknown,” (Marley 1997).
Due to the current lack of information surrounding the subject, caution must be practiced by the pharmacist, lest an overmedication of the populace occur much the same way Aspirin was over prescribed for some older generations. The audit used for patient evaluation is highly useful in determining a future course of action for a potential patient. Beginning with a description of current symptoms and previous therapy, the audit lays out the alternatives to PPI use, if necessary, in a well laid out manner. It also serves as a reminder of the exchange necessary at the counseling encounter for the patient to use the drug effectively.