The Second War on PPIs

At a meeting today we were on the verge of war on proton pump inhibitors.

Let me back up and explain. Like many NHS trusts, we're pulling out all the stops on battling that huge threat to mankind, Clostridium difficile. For those who don't get a shudder down the spine by the sound of that bacterial species, DoH provides some useful background. In brief, if you give an elderly patient an antibiotic that removes most of their gut bacteria and put them in a hospital environment, there's a fair chance that these Clostridium difficile bacteria will get a foothold and multiply to the point where the patient develops mild to lifethreating diarrhoea. This diarrhoea then sprends the bacteria's spores to other patients, and you end up with your trust on the front page of the tabloids.

We've done (or are doing) the obvious. Time for the not so obvious - and the large number of patients who end up with C. difficile who also take proton pump inhibitors is making our people consider declaring war on unnecessary PPIs.

Now this association between isn't particulary new, Bandolier reported on a study about it in 2003. It's also difficult to prove in the large population, most studies only show an association and hence don't prove causation. However the number of months of our data that indicated that PPI use is shown as great a risk factor as antibiotic use makes it a potential target.

But this isn't the first time I've witnessed a war by pharmacists on PPIs. One estimate is that 25-70% of PPI use is unnecessary, that patients with mild GORD or dyspepsia get started on them by a doctor with a very nice Zoton pen, and then never adequately reviewed to stop them. One hospital I used to work at had a cardiology team that would routinely start them for patients with non-MI chest pain, just in case. The problem with PPIs is - just like with cephalosporin - they're just too damn useful.

The first PPI war, which wasn't particularly succesful, was due to waste - of drug budgets and patient's concordance with a drug they didn't need. Now it's a matter of patient safety - one of the current NHS mantras.

So dear reader (of whom I know there are at least 3 ;) - I would greatly value any tips on reducing PPI's - either from a hospital or PCT perspective. Any advice?

3-9-8