Heartburn drugs can do more harm than good

| October 25, 2019

A new UNSW study has found that national initiatives were unsuccessful in reducing prolonged use of anti-acid medicines for gastrointestinal acid-related disorders and more targeted interventions are needed.

Education campaigns to curb Australians’ widespread use of popular anti-acid medicines – linked to long-term health risks – have been insufficient, a new UNSW study published today in BMJ Quality & Safety has found.

In 2017, an estimated 15 per cent of Australian adults took at least one proton pump inhibitor (PPI) medicine to manage gastrointestinal acid-related disorders, such as moderate to severe heartburn or acid reflux. Globally, PPI usage is estimated at seven to 16 per cent.

First author Claudia Bruno, from UNSW Medicine’s Centre for Big Data Research in Health, said PPI medicines were appealing for doctors and patients to treat anti-acid conditions. However, prolonged use might lead to health problems, particularly for older people.

“PPIs are safe in the short-term, effective and generally well tolerated. Many patients stay on these medications for long periods without trying to reduce or stop treatment. It’s tempting to stay on a medicine which has provided good symptom relief,” Ms Bruno said.

“But there are growing concerns about taking these medicines longer than is clinically necessary. Long-term use is associated with increased risks of bone fractures, vitamin B12 and magnesium deficiencies, and gastrointestinal infections, especially in older people.

“And, recent evidence suggests an increased risk of death with prolonged PPI use, specifically because of cardiovascular disease, chronic kidney disease and upper gastrointestinal cancer.”

Most conditions do not require ongoing use of PPIs. Guidelines for standard strength PPI treatment recommend using the drug for no longer than four to eight weeks, unless symptoms continue to persist.

National education campaigns

The UNSW research evaluated the impact of the NPS MedicineWise educational initiative and the Choosing Wisely recommendations, both national campaigns launched in 2015 to curb escalating and potentially inappropriate PPI use.

The study analysed data from more than 12 million PPI prescriptions to almost 600,000 people between 2012-13 and 2017-18. They showed a 1.7 per cent decline in monthly dispensing of standard strength PPIs following the education campaigns until the end of the study period.

In addition, despite the promotion of reducing or discontinuing PPI treatment in these initiatives, the study found no change in the rates of switching to lower PPI strengths or stopping treatment.

The median age of PPI users was 57 years old.

Ms Bruno said the study findings were unsurprising, given that it generally takes intense interventions to significantly change people’s behaviour – that of doctors and patients.

“We had no expectations of large-scale, national change because the campaigns we studied mostly disseminated the information. This is necessary to drive change, but generally successful interventions have more active measures including educational visits to doctors,” she said.

“Once a medicine has been prescribed, many factors contribute to continued use of medicines. It can be a lot harder to stop therapy than to prescribe the medicine in the first place.

“For people taking PPI medicines or about to start treatment, we suggest taking the time to discuss with your doctor an appropriate treatment plan and regular review. Often patients might benefit from stepping down treatment or stopping long-term use.”

New initiatives to reduce prolonged PPI use

Ms Bruno said she hoped to do further study on the impact of new policy interventions and education campaigns launched after the research ended.

The Australian Government introduced restrictions on the prescribing of subsidised PPI drugs in May this year.

“The new restrictions aim to further encourage the use of lower strength PPIs and to limit long-term treatment of higher strength PPIs to clinically appropriate cases, so we are excited to see what impact these efforts will have,” Ms Bruno said.

“There is also a new NPS MedicineWise education program on PPIs, which is a more intensive campaign.

“In addition, more patients might reduce treatment if a low strength version of the most commonly prescribed PPI, esomeprazole, was publicly subsidised in tablet form.”