Dr Mark Cottrill explains why the NICE guidance may fail to achieve its aim of reducing the cost of PPI prescribing
In the past two decades there have been dramatic advances both in our understanding of disease mechanisms and in new treatment options. While patients have benefited from such advances, there has been an exacerbation in drug costs.
The NICE guidance on the use of proton pump inhibitors (PPIs) in the treatment of dyspepsia may succeed in increasing awareness of the principles of the use of these drugs in primary care. Any treatment should be effective and appropriate, and patients should not be overtreated. The NICE report, however, has significant workload implications for GPs.
The recommendations aim to reduce costs, but any savings are likely to be taken up with more investigations and changes to potentially more costly treatments. No account is taken of the cost of the GP's time spent on audit or on increased consultations.
For peptic ulcer disease, NICE recommends eradication of Helicobacter pylori when detected. This is 'old news', and there can be few patients taking PPIs for H. pylori-related ulcers, other than when antibiotic treatment has failed. New ulcers are rare in the under-45s: Heikkinen et al quote a rate of 4%.1 The report quotes an incidence of 15-25% in adults presenting with dyspepsia.
Management of gastro-oesophageal reflux disease (GORD) is less clear. Healing doses of a PPI are recommended for patients with 'severe' symptoms, reducing to a maintenance dose once such symptoms have been controlled. Severity of symptoms may be difficult to define and does not correlate well with endoscopic appearance.
The guidance takes no account of the presence (or absence) of mucosal damage. When mucosal damage is present it would seem more appropriate to provide a healing dose for 4 or 8 weeks, after which time treatment could be stopped in many patients – so-called 'pulse' therapy.
The report further suggests that the maintenance dose can be reduced in 70–80% of patients. In my own practice audit this figure was closer to 50% and Bardhan et al quote a figure of 60%.2 Furthermore, in my audit a surprising number of patients needed additional antacids.
The general guidance is that non-ulcer dyspepsia (NUD) is not acid related and 'alternative treatment' is often more appropriate. In practice, it could be strongly argued that the only test of an acid-related problem is a trial of PPI therapy in full doses for a short period. If there is no response it can be assumed that the disorder is not acid-related! This approach would save the costly option of referral.
What are the implications for GPs? Formal audit of PPI prescriptions is recommended, but would involve considerable work. Opportunistic review may be more realistic. Even a review is likely to result in more gastroscopy referrals to units already trying to cope with the '2-week referral' rule for suspected cancers.
The object of the guidance is to reduce the cost of PPI prescribing and this could be achieved with appropriate prescribing. This is seemingly logical, but the GP needs to be aware of the licensed indications for the different PPIs. It may be difficult to change a patient established on a particular PPI on the basis of cost alone, only to change again when a cheaper (or generic) version becomes available.
Such changes may result in further consultations and more investigations, and may not be in the patient's best interests. Switching from a low-dose PPI to a histamine H2-antagonist may not be cost efficient. Some cost more than the lowest priced PPI and patients may require additional antacids.
Will implementation of the guidance reduce the cost of PPI prescribing? I think not.
- Heikkinen M et al. Scan J Gastroenterol 1995; 30(6): 519-23.
- Bardhan KD et al. Gut 1998; 45: 458-64.