{"id":50705,"date":"2023-09-30T10:50:55","date_gmt":"2023-09-30T10:50:55","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=50705"},"modified":"2023-10-07T11:15:32","modified_gmt":"2023-10-07T11:15:32","slug":"knowledge-attitude-and-practices-of-resident-doctors-towards-use-of-proton-pump-inhibitors-in-a-tertiary-care-hospital-in-pune-india-a-cross-sectional-survey","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no3\/knowledge-attitude-and-practices-of-resident-doctors-towards-use-of-proton-pump-inhibitors-in-a-tertiary-care-hospital-in-pune-india-a-cross-sectional-survey\/","title":{"rendered":"Knowledge, Attitude and Practices of Resident Doctors Towards use of Proton Pump Inhibitors in A Tertiary Care Hospital in Pune, India: A Cross-Sectional Survey"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

Proton\npump inhibitors (PPIs) are one of the most commonly used types of drugs in the\nworld, and there are many articles about how to use them correctly and how not\nto use inappropriately.1-4<\/sup> There are reports indicating PPI\nprescriptions have climbed dramatically worldwide.1,5-8<\/sup> Global\nstudies have also revealed that the excessive use of PPIs in both intensive and\nnon-intensive care settings places a significant financial burden on\nhealth-care systems.1,5,9 <\/sup>However, a systematic assessment of the\nattitudes and practices of health care providers towards the use of these drugs\nfor improving the rational use of PPIs in developing countries, including\nIndia, is lacking.10-12<\/sup> For a variety of GI diseases related to\nacid, proton pump inhibitors (PPIs) are among the most commonly prescribed\nmedications in healthcare systems. There are published recommendations and\nguidelines for using PPIs in various clinical conditions.13-15<\/sup><\/p>\n\n\n\n

Despite\nthe existence of guidelines, many studies have noted the uncontrolled use of\nthese medications. Even in the absence of risk factors, PPIs are frequently\nadministered to patients who are on nonsteroidal anti-inflammatory drugs\n(NSAIDs).3,9<\/sup> This method can make it more likely that a drug will\nhave side effects and be a waste of money. PPI medication for a short period is\nusually well tolerated. Continuous PPI usage, however, has been associated with\na greater risk of infections, osteoporosis, and other significant side effects,\nincluding fractures, bone marrow toxicity, community-acquired pneumonia, Clostridium\ndifficile diarrhea, etc.16<\/sup><\/p>\n\n\n\n

As\nthere are few studies from developing nations on the extent of prescribing and\nappropriateness of PPI use, the attitudes and behaviors of healthcare professionals\nregarding the use of this class of drugs need to be rigorously evaluated.10-12<\/sup><\/sup><\/p>\n\n\n\n

For\nthe application of PPIs to be more logically justified, resident doctors’\nknowledge of PPIs is crucial. In view of this, we conducted a\nquestionnaire-based study to assess resident doctors\u2019 knowledge, attitude, and\nprescribing practices of gastric acid suppressants, particularly PPIs, at a\ntertiary care hospital in western India.<\/p>\n\n\n\n

Material and Methods<\/strong><\/p>\n\n\n\n

A\ncross-sectional, observational study among resident doctors from clinical\nbranches in a tertiary care teaching hospital in Pune, Western India, was conducted.\nThe study was approved by the Institutional Ethics Committee (BVDUMC\/IEC\/E4),\nand written informed consent was obtained from all the participating resident\ndoctors. An extensive search of the literature on the internet turned up little\ninformation about the prevalence of awareness of the proper usage of PPIs among\nresident doctors, particularly in developing countries in a tertiary care\nhospital. The sample size calculations were thus based on the assumption that\n50% of the residents had correct knowledge regarding the rational use of PPIs.\nwith a 95% confidence limit and a 5% tolerance for error applied in the Rao\nsoftware online formula17,18<\/sup> to estimate a reasonable sample size,\nwhich amounted to 137 participants. Hence, of the total 212 resident doctors in\nour study setup, we surveyed 137 resident doctors of clinical departments who\nwere involved in prescribing PPI [Medicine, Surgery, Gynecology, Orthopedics,\nAnesthesiology].<\/p>\n\n\n\n

The\nstudy questionnaire was created after referring to similar kinds of research\nstudies carried out in other clinical settings.10,19,20<\/sup> The\nquestionnaire’s first section included demographic data such as name, age, and\ngender, followed by the knowledge-assessing section, which included queries\naimed at gathering data such as correct choice, recommended method of delivery,\nand required duration of gastric acid-reducing medications. In the following\nsection, resident doctors’ viewpoints were included, along with how well they\ncomprehended the course of treatment and were aware of the risks of PPI use.\nInquiries regarding common indications and dangers, as well as potential risks\nassociated with long-term PPI usage, had a choice of many responses to opt for.<\/p>\n\n\n\n

Before\nthe major survey, the questionnaire was given to relevant professionals in the\nfields of pharmacology and medicine for scrutiny. The designed questionnaire\nwas pretested among ten resident doctors in a comparable setting (pilot study).\nThe questionnaire was adjusted in light of expert recommendations and results\nfrom a pilot study. The necessary modifications had been incorporated in the\nfinal questionnaire and utilized among study participants.<\/p>\n\n\n\n

Statistical\nAnalysis: Data were entered into Microsoft Excel (MS Office 2008), and\nstatistical analyses were conducted using SPSS version 28.0 (IBM SPSS,\nChicago). The results are presented as frequencies and percentages.<\/strong><\/p>\n\n\n\n

Results<\/strong><\/p>\n\n\n\n

137 resident doctors from chosen\nclinical branches completed the questionnaire, and the majority of them were\nmale resident doctors (64%), with an average age between 20 and 30 years.<\/p>\n\n\n\n

The resident doctors’ drug\nprescriptions were based on the consultant’s or unit’s policy, which is common\nin tertiary care practices, and they were not given any flexibility in doing\nso.<\/p>\n\n\n\n

100% of the respondent doctors confirmed\nthat they had given their patients antiulcer medications.<\/p>\n\n\n\n

82.5% reported prescribing\nacid-suppressing medications (PPI and H2 blockers) for the majority of their\npatients, 3.6% of whom almost always administered them. About 71% of\nrespondents reported PPIs were often the first acid-suppressing medication they\nhad chosen, and 75.1% of them preferred the oral route for their\nadministration. The majority of the study participants (75.9%) prescribed PPI\nonce daily for a duration of less than 1 week, which is the recommended\nduration. Also, the majority of the resident doctors (92%) knew that oral PPI\nintake should be in the morning before breakfast.<\/p>\n\n\n\n\n\n
\"\"<\/td>\n\n

Figure 1: Indications for prescribing acid suppressing
drugs according to study participants.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

The\ncommonest indication for which resident doctors prescribed acid suppressive\ndrugs were acute gastritis (89%) in combination with other drugs (84%),\nfollowed by prophylaxis against stress ulcers. (39%) [Figure 1]\n\n\n\n

Only 14 resident doctors (10.2%)\nreported experiencing a PPI-related adverse event and specifically mentioning\nnausea, vomiting, and diarrhea as the adverse events. When asked about any\npossible adverse effects with PPI, a total of 94 responses were received from\nthe 88 participants (64.2%) who opted to respond to this question. According to\nthe responses on the awareness of the risks inherent with long-term usage of\nPPIs, just 16% of the participants were aware of a higher risk of\ncommunity-acquired pneumonia, 48% knew about Clostridium difficile infection,\nand 30% knew about hip fractures or osteoporosis as a long-term risk with PPI.       [Figure 2]\n\n\n\n\n\n
\"\"<\/td>\n\n

Figure 2: Participants\u2019 knowledge about adverse effects on long term use of PPI<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Table 1: Participants\u2019 knowledge about drug interactions with PPI<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n
\n

Drugs <\/strong><\/p>\n<\/td>\n

\n

No. of responses<\/strong><\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Aspirin<\/p>\n<\/td>\n

\n

12<\/p>\n<\/td>\n

\n

8.8<\/p>\n<\/td>\n<\/tr>\n

\n

Warfarin<\/p>\n<\/td>\n

\n

33<\/p>\n<\/td>\n

\n

24.1<\/p>\n<\/td>\n<\/tr>\n

\n

Digoxin<\/p>\n<\/td>\n

\n

15<\/p>\n<\/td>\n

\n

10.9<\/p>\n<\/td>\n<\/tr>\n

\n

Iron<\/p>\n<\/td>\n

\n

48<\/p>\n<\/td>\n

\n

35<\/p>\n<\/td>\n<\/tr>\n

\n

Any other<\/p>\n<\/td>\n

\n

0<\/p>\n<\/td>\n

\n

0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

83 (60.6%) residents stated that drug interactions can happen with the co-administration of PPI with other medications. When persistently administered with PPIs, they found that medications like iron (35%) and warfarin (24%), besides a few others, can cause clinically significant interactions. Unfortunately, none of the participants was aware that all drugs mentioned in Table 1 could have possible drug\u2013drug interactions when co-administered with PPIs.<\/p>\n\n\n\n

In\nresponse to an open-ended inquiry about recommendations for therapeutic\napproaches while using acid suppressing agents, 19.7% of participants were\nunable to name any such approach. When prescribing PPI to their patients, 58.4%\nof resident doctors preferred using the step-down strategy, while 21.9% of\nparticipants preferred the step-up approach. Only 5.1% of the respondents who\nanswered correctly stated that they should wait seven to eight weeks before\nswitching from one strategy to another. Only 13.13% of the resident doctors in\nthe study suggested that GERD patients should change their lifestyle.<\/p>\n\n\n\n\n\n
\"\"<\/td>\n\n

Figure 3:  Study Participants\u2019 Practice- approach while prescribing the PPI.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Discussion<\/strong><\/p>\n\n\n\n

PPI\nis overused and often used without proper justification, according to several\nstudies worldwide.3,5,9,21,22<\/sup> Appropriate and updated knowledge\nabout PPI among medical professionals is essential to enhance the rationale of\nPPI application. There are not many studies evaluating prescription drug usage\nand the appropriateness of using PPI in developing countries, including India.1,10<\/sup>\nIn view of this, the present study was initiated to evaluate the understanding\nand behavioral practices toward PPI use among the resident doctors in the study\nsetting.<\/p>\n\n\n\n

The\nextent of use of drugs for reducing gastric acid was high in the present study\nand among the majority of the study participants. PPIs were the\nacid-suppressing medication of choice for 71.5% of respondents. Our study\nfindings are similar to those of earlier studies 1,10,22<\/sup> conducted\nin India and other developed countries where the majority of patients were\nprescribed acid-suppressing medications and PPI was the top choice among\nthese medications. Though the majority of resident doctors preferred oral PPIs,\nsome of them opted for intravenous PPI for acid suppression in their hospitalized\npatients. The authors have mentioned that parenteral PPIs are frequently\nprescribed by doctors instead of oral PPIs to achieve higher therapeutic\nefficacy.10,12<\/sup> Oral PPI appears to be as effective as parenteral\nPPI, and only a small percentage of patients with upper GI bleeding require parenteral\nPPI administration.23<\/sup><\/p>\n\n\n\n

Prescription\nof acid suppressive agents in acute gastritis is appropriate and has been found\nin other studies such as this one, but treatment in these cases should ideally\nbegin with H2 blockers and be stepped up to PPI after 6-8 weeks if necessary.\nStep-up therapy (treat for eight weeks with H2 blockers; if symptoms do not\nimprove, switch to PPI) or step-down therapy are the preferred empiric\napproaches (treat initially with PPI; then titrate to the lowest efficient drug\ntype and dosage). 19.7% of the study respondents were unable to name any such\napproaches while prescribing PPI to their patients. Our research revealed that\na significant percentage of doctors chose PPIs over H2 blockers, and as a\nresult, it was impossible to avoid a rise in treatment costs. The selection of\nappropriate approaches for PPI prescriptions was not implemented in the current\nsystem with valid indications. Proven techniques, including step-down, step-up,\nand on-demand therapy with PPIs, should be applied in our tertiary teaching\nhospital in order to optimize the cost-effectiveness of PPI-based treatment.24<\/sup>\nBecause the prescription of drugs, including PPIs, by resident doctors is\nprimarily determined by the consultant’s policy, educational interventions to\nall clinicians, including resident doctors, for appropriateness and\nencouragement for step-down approaches following regular review of ongoing\nindications for PPI use, as well as de-prescribing PPI policy without valid\nindication, could be beneficial.<\/p>\n\n\n\n

A\nPPI is the first-line treatment for patients with erosive esophagitis noticed\nduring an endoscopy. PPIs, as \u201cprophylactic” gastro-protective\nmedications, were mentioned by study participants as being prescribed to\npatients on NSAIDs, similar to other studies.3,9,10<\/sup> But it is\nillogical to recommend PPI to every patient who takes NSAIDs.25<\/sup>\nPatients suffering from chronic conditions who need NSAIDs should be given\ncoxib, misoprostol, or a PPI if GI risk factors are present. However, without a\nthorough assessment of their GI risk factors, such patients are frequently\noffered gastro-protective medications on an empirical basis.10<\/sup> From\na scientific perspective, even consistently administering PPI to the majority\nof in-patients without evident reasons is inappropriate. National and\ninternational guidelines specifying the rational indications for prescribing\nPPI are available and should be referred to by clinicians during their\npractice.13-15<\/sup><\/sup><\/p>\n\n\n\n

Even\nthough the majority of our respondents opted to only administer PPIs for short\ndurations (75.9%), we noted a lack of awareness about the possible risks associated\nwith long-term PPI usage. According to their understanding of the risks\ninherent with prolonged use of PPIs, just 16% of the resident doctors were\naware of a higher risk of community-acquired pneumonia. The hazards of\nClostridium difficile infection and hip fractures or osteoporosis associated\nwith chronic use of PPI were also less well understood.16<\/sup> A study by\nPatel et al. on the usage of acid suppressants also concluded that excessive\nPPI prescriptions may be a risk factor for negative side effects, medication\ninteractions, additional cost, and even incorrect prescriptions.26<\/sup>\nAccording to a recent study, Wu B et al reported six AKI (acute kidney injury)\nand CKD (chronic kidney disease) signals related to PPI. The median duration\nfor CKD was greater than for AKI; however, the authors here indicate that a\nsignificant percentage of patients experienced renal damage after one year of\nPPI medication. A meta-analysis by Yang et al. in 2017 also revealed that PPI\nuse might be linked to untoward effects on the kidneys in patients with certain\nrisk factors, like young age, high-dose PPI use, existing kidney damage,\nconcurrent use of nephrotoxic agents, etc. Hence, PPI-associated kidney injury\nshould be considered a major risk with chronic use of this class of drugs, and\nthe significance of prudent PPI use should be highlighted in clinical settings.27,28<\/sup><\/sup><\/p>\n\n\n\n

In the present\nstudy, 61% of residents stated that drug interactions can happen with the co-administration\nof PPI with other medications. But besides one or two drugs mentioned in Table\n1, none of the participants was aware that all drugs mentioned could have\npossible drug\u2013drug interactions when co-administered with PPIs. Inappropriate\nPPI prescriptions may cause adverse drug reactions. Only a small number of\nPPI-drug interactions are clinically important, since different PPIs have\nvarying propensities to interact with other medications. According to a study\nconducted by Blume H et al., in contrast to lansoprazole, pantoprazole, and\nrabeprazole, which have lesser affinities for particular CYP isoenzymes,\nomeprazole and esomeprazole have a higher possibility for drug interactions\n(high affinity for CYP2C19 and moderate affinity for CYP3A4).29<\/sup><\/p>\n\n\n\n

Doctors’\nlack of knowledge of these could exacerbate the problem of PPI usage.\nTherefore, rational prescribing is necessary when using PPIs in hospital practice.\n<\/p>\n\n\n\n

There is no institute or unit policy\nin the current study set up for prescribing PPIs with documentation of\nindications in accordance with guidelines. Rational PPI use can benefit from\nsimple, resident-driven quality improvement initiatives that use valid\napproaches for reviewing the patient’s indication. Also, specific measures like\nregular audits, feedback to prescribers, and educational interventions for\nrational prescribing of PPIs may be helpful in preventing PPI abuse.<\/p>\n\n\n\n

Despite\nthe helpful findings gathered from our study, a few limitations need to be\nmentioned. Firstly, our findings regarding knowledge, attitude, and behavior\nabout PPI usage among resident doctors may be influenced by self-reporting bias\nand an overestimation of positive information. Secondly, the applicability of\nthe findings from this data may be constrained because this survey only\nincluded resident doctors in a single tertiary teaching hospital.<\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

PPI\noveruse is still a regular practice in Indian hospitals. There is a lack of\nunderstanding about the proper indications for PPI use, as our study\nparticipants recommended PPI over any other acid-reducing medication to the\nmajority of their patients, primarily as a consultant’s policy. Low level of\nknowledge regarding adverse drug reactions, drug-drug interactions with PPIs,\nand specific approaches for PPI delivery regimens was also noticed.<\/p>\n\n\n\n

Conflict of Interest <\/strong><\/p>\n\n\n\n

There is no conflict of interest<\/p>\n\n\n\n

Funding Sources<\/strong><\/p>\n\n\n\n

There are no funding source<\/p>\n\n\n\n

References<\/strong><\/p>\n\n\n\n

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    Introduction Proton pump inhibitors (PPIs) are one of the most […]<\/p>\n","protected":false},"author":15,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[109],"tags":[],"class_list":["post-50705","post","type-post","status-publish","format-standard","hentry","category-vol16no3"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/50705","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=50705"}],"version-history":[{"count":5,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/50705\/revisions"}],"predecessor-version":[{"id":52643,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/50705\/revisions\/52643"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=50705"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=50705"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=50705"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}