Individuals, health care institutions and Alberta Blue Cross spend millions of dollars for the use and “abuse” of pills for indigestion, heartburn and the treatment of peptic ulcer disease. Is there a sensible way of using these pills?

Recently, this subject was discussed in the DUE (drug use in the elderly) Quarterly.

Dyspepsia (indigestion) affects 29 percent of the adult population and accounts for seven percent of visits to family physicians.

Most widely prescribed and used acid suppressing agents are:

-Proton pump inhibitors (PPI)- accounts for 90 percent of Alberta Blue Cross Group (ABCG) 66’s cost of acid suppression agents (examples-Losec, Prevacid, Pantaloc)

-H2 antagonists –accounts for 10 percent of the ABCG 66’s cost of acid suppression agents (examples-Zantac, Pepcid, Axid and their generic versions)

Why would one need these pills?

-For eradication of Helicobacter pylori organism from the stomach. A protocol requires that any patient with H. pylori infection, in the presence of an ulcer, should receive one week of “triple therapy” – two antibiotics and PPI. In the absence of an ulcer, the use of “triple therapy” is controversial.

-For gastroesophageal reflux disease (heart burn) – four to eight weeks of treatment with PPI or H2 antagonist is indicated with life-style changes.

-For functional dyspepsia, also known as non-ulcer dyspepsia or indigestion. In this condition, an individual has all the symptoms of an ulcer but no ulcer is found on investigations. A difficult condition to treat satisfactorily. A person may end up using the pills for prolonged period of time for symptomatic relief.

-For NSAID-related dyspepsia – individuals who are on non-steroid anti-inflammatory drugs (NSAID) are prone to peptic ulcer disease or indigestion. These individuals are on long-term use of stomach pills.

Losec should be taken half an hour before any meal, while Pantaloc and Prevacid should be taken before breakfast. These pills should be taken whole, not broken or chewed.
The Quarterly says that PPI have been recognized to be efficient and safe in what they do. And there is not much difference in the clinical use of the three PPIs except for the cost.

The cost comparison of PPIs in Alberta shows that Losec 20mg once daily costs $66.00 per month, Pantaloc 40mg once daily costs $61.26 per month and Prevacid 30mg once daily is the cheapest at $60.00 per month.

The largest group of patients on PPI are the ones with heartburn and gastroesophageal reflux disease. Many of these patients can be treated with life style changes and over the counter medications and/or cheaper H2 receptor antagonists like Zantac, Pepcid, or Axid. Those who do not respond to these measures can be stepped up to a PPI. These patients also require investigations to assess the degree of damage to the lining of the oesophagus by gastric and biliary juices.

The next large group on PPI is one with indigestion due to NSAID use. Patients who have peptic ulcer due NSAID therapy are best treated with PPI. NSAID patients are usually on another drug called misoprostal, which offers protection against development of ulcers.

Patients with non-ulcer dyspepsia should not be on long term PPI therapy without trial of other therapies, which are cheaper, and with minimal side effects. Prolonged acid suppression in the stomach without good reason may lead to atrophy of stomach glands and deficiency of vitamin B12. Plus the cost to the patient and other institutions that pay for the prescriptions.

So, if you are on any of the pills mentioned here on long term basis then ask your doctor: Do I really need it? Is there anything cheaper? Is there anything else you can do to relieve your symptoms?

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