Description of the Use of Proton Pump Inhibitors (PPIs) in Adults Covered by the Public Prescription Drug Insurance Plan

Proton pump inhibitors (PPIs) are some of the most widely used and most expensive drugs in Québec. The high cost associated with the use of PPIs led the Québec government to consider a number of steps aimed at improving their use. Thus, key messages directed at physicians and pharmacists were developed in 2002 and updated in 2009.

Key messages:

1. Once a day. A single daily dose taken 30 minutes before breakfast is adequate to treat and relieve symptoms.
2. PPIs: not necessarily for life. The first prescription should be for 4 weeks for the treatment of uninvestigated dyspepsia with or without major symptoms of gastro-esophageal reflux. Re-evaluation after 4 weeks promotes optimal use of PPIs.
3. Individualized treatment. When the initial treatment with a PPI has relieved the symptoms, follow-up treatment should then be individualized.
4. Cost effectiveness. Given that the different PPIs have equivalent clinical effectiveness overall, the less expensive products are recommended. 

The study’s objectives were to describe PPI use, from 2007 to 2012, among adults aged 18 years or over who were covered by the Public Prescription Drug Insurance Plan and to compare this use with optimal utilization criteria in order to assess compliance with them. A retrospective cohort study was carried out using three databases administered by the Régie de l’assurance maladie du Québec (RAMQ). 

The results of this study provide a brief overview of the practice and will give PPI prescribers food for thought regarding their prescribing habits. This reflection should mainly concern the frequent PPI treatments of 12 or more weeks’ duration and the fact that there was no medical visit in 20% of new PPI users within the year following the start of treatment. The difficulty in providing a close follow-up of all patients who are not very ill probably explains the low level of compliance observed for the second and third optimal utilization criteria. Improvement in PPI use does, however, seem possible. This improvement would require a better follow up or evaluation of the treatment indication. We can even suppose that a better assessment of the treatment indication may improve use. The preferred use of generic rabeprazole might also substantially reduce the cost of PPIs for the Public Prescription Drug Insurance Plan with no loss of efficacy in most users.