Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice Research Database

BMJ 1998;317:452-456 ( 15 August )

General Practice

Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice Research Database

James N R Bashford, lecturer, primary care research, Jeff Norwood, consultant in public health medicine, Stephen R Chapman, professor of prescribing studies.

Department of Medicines Management, Keele University, Keele ST5 5BG

Correspondence to: Professor Chapman

Objectives: To establish the relation between new prescriptions for proton pump inhibitors and recorded upper gastrointestinalmorbidity within a large computerised general practitionerdatabase.
Design: Retrospective survey of morbidity and prescribing data linked to new prescriptions for proton pump inhibitorsand comparison with licensed indications between 1991 and 1995.
Setting: General Practice Research Database and prescribing analysis and cost (PACT) data for the former West Midlands region.
Subjects: Information for 612 700 patients in the General Practice Research Database. Anonymous PACT data for all generalpractitioners in West Midlandsregion.
Main outcome measures: Diagnostic codes linked to the first prescriptions issued for proton pump inhibitors; relationbetween new prescriptions and licensed indications; yearly changein ratio of new to repeat prescriptions and prescribing volumesmeasured as defined dailydoses.
Results: Oesophagitis was the commonest recorded indication in 1991, accounting for 31% of new prescriptions, but wasthird in 1995 (14%). During the study new prescriptions increasedsubstantially, especially for duodenal disease (780%) and non-ulcerdyspepsia (690%). In 1995 non-specific morbidity accounted for46% of new prescriptions. The total volume of prescribing rose10-fold between 1991 and 1995, when repeat prescribing accountedfor 77% of thetotal.
Conclusions: Changes in recorded morbidity associated with new prescriptions of proton pump inhibitors did not necessarilyreflect changes in licensed indications. Although general practitionersseemed to respond to changes in licensing, particularly for duodenaland gastric disease, prescribing for unlicensed indications non-ulcerdyspepsia and non-specific abdominal pain increased.

Key messages

There has been much speculation about the reasons behind the substantial rise in prescribing of proton pump inhibitors, especially their use for minor symptoms.
We used the General Practitioner Research Database for the former West Midlands region to show that the volume of proton pump inhibitor prescribing rose 10-fold between 1992 and 1995 and repeat prescribing had risen to 77% of the volume by 1995
Prescribing for uncomplicated dyspepsia and non-specific abdominal symptoms, which were outside the licensed indications, accounted for 46% of new prescribing by 1995
The proportion of prescribing for the licensed indication of oesophagitis fell during the study, but that for duodenal ulceration increased in line with the expansion of licensed indications
Analysis of PACT data showed similar prescribing trends to those found with the General Practitioner Research Database

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