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Capsule Commentary on Gawron et al., Proton Pump Inhibitor Prescriptions and Subsequent Use in US Veterans Diagnosed with Gastroesophageal Reflux Disease
Shoshana J. Herzig
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Beth Israel Deaconess Medical Center
, Brookline,
MA, USA
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I Hospital, Gawron et al.1 examined characteristics of
n this single-center study conducted at the Hines, IL, VA
initial and subsequent proton-pump inhibitor (PPI)
prescribing in veterans within 30 days of an ICD-9 code for
gastroesophageal reflux disease in the outpatient setting.
They found that of these initial PPI prescriptions, 23.3 %
were high dose, and the majority were for 90 days or more.
Only 11.9 % of patients receiving an initial high-dose
prescription and 3.3 % of patients overall had evidence of
step-down therapy. Additionally, 83.8 % of patients
received at least one refill, with a high medication possession
ratio over 2 years. Taken together, these data suggest that
few patients are receiving or successfully completing a trial
of step-down or discontinuation of therapy.
Unfortunately, because prescription data do not
necessarily reflect the communication between physician and
patient, we are unable to know whether the low rate of
step-down or discontinuation of therapy represents a failure
of physicians to recommend such a trial or a failure of
patients to tolerate it. However, the findings of Inadomi et
al.2 that many, if not most, patients can tolerate step-down
therapy suggest that the former is more likely. Furthermore,
the high medication possession ratio in this study suggests
that continuous rather than on-demand use is predominant.
These results draw attention to the main problem
plaguing this highly effective class of medications: once
patients are on PPIs, they tend to stay on them. While the
reasons for this are manifold, research suggests that many of
these prescriptions are unnecessary, and physicians all too
often fail to assess the necessity of continued use.3,4 This
study highlights the great need for the development of
strategies to prompt periodic re-evaluation of the need for
all medications on a patients medication list. The same
sophisticated computerized system that makes ordering and
refilling prescriptions at the VA so easy could also provide a
solution, in the form of computerized clinical decision
support. The most efficient and effective means of such
comprehensive medication managementfor PPIs and
beyondis not yet clear and will be an important focus of
future studies.
Conflict of Interest: The author of this manuscript does not have
any relevant disclosures or conflicts of interest to report.
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