High Doses, Long Durations: Veterans and GERD Treatments

A study including military veterans indicates that proton pump inhibitors are frequently prescribed for extended periods at higher-than-recommended doses.

Military veterans with gastroesophageal reflux disease (GERD) are often prescribed medication for too long and at doses higher than those recommended to control their conditions, according to the results of a study published in the February 2013 edition of the Journal of General Internal Medicine.

A team of researchers at Northwestern University evaluated more than 1600 veterans with GERD who received the proton pump inhibitors (PPIs) esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole from 2003 through 2009. PPIs are among the most widely used drugs in the United States; more than 50% of prescriptions for all digestive disease are for PPIs, and the medications consume more than $11 billion in direct health care costs. Rational prescribing and careful monitoring are needed to avoid unnecessary, prolonged use.

The researchers found that the majority of the study participants were treated empirically and received more than a 3-month initial supply of PPIs. Nearly 25% received higher doses than necessary. Documentation in charts was considered poor, with few prescribers (<20%) indicating that the patient was told when to take the PPI. Two years after their initial prescription, only a few patients on high doses had been “stepped down” to the usual dose.

“We should always have a re-evaluation after an initial prescription and ask, ‘Does this patient need to be on this medication?’” said first study author, Andrew Gawron, MD, of Northwestern University, in a press release. “Proton pump inhibitors are provided ubiquitously in medicine, and although they provide relief for many patients, optimal prescribing is important to avoid prolonged, unnecessary use and cost.”

The FDA-approved starting course for all PPIs is 4 to 8 weeks at the lowest effective level. If symptoms continue after 8 weeks, doctors are supposed to look for other causes and more effective treatments. The American Board of Internal Medicine and the American Gastroenterological Association made this approach a top priority last year in its Choosing Wisely campaign.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.