Overview of proton pump inhibitor use: a medical scheme perspective.

Abstract

Background: Proton pump inhibitors (PPIs) are highly effective and safe drugs for the treatment of acid-related disorders. However, their easy availability over-the-counter (OTC) often results in the misuse of these drugs. Inappropriate prescribing practices also lead to overutilization, leading to potential long-term adverse effects and rising cost implications on medical schemes. This study aims to provide an overview of PPI misuse and the financial implications on medical schemes in South Africa. Method: Retrospectively, all acute and OTC PPI claims from four different medical schemes from January 2021 to December 2021 were extracted from an electronic database of a pharmaceutical benefit management organization. A total of 268 537 claims made by 81 566 patients were included in the study. The data obtained were recorded on Excel® and included patient age, sex, generic entity including strength and quantity claimed, prescriber and provider types, month claimed, benefit applicable and the cost reimbursed by the medical scheme per claim in South African Rands. Descriptive and analytical measures were used to evaluate the frequency and duration of PPI usage, provide an overview of the safe indications for use and determine the overall financial impact of PPI usage on medical schemes. Results: Five different PPI generic entities were analyzed (pantoprazole, omeprazole, lansoprazole, rabeprazole and esomeprazole). PPIs were claimed at an average of 8 times within the twelve-month period per patient. There was a significant correlation between the patient’s age and the duration of therapy (p < 0.001). Omeprazole (34%), pantoprazole (25%) and esomeprazole (24%) were the most frequently utilized generic entities. More than half of the PPIs claimed were prescribed by general practitioners. Lansoprazole 15 mg, omeprazole 10 mg and 20 mg and pantoprazole 20 mg are available for OTC usage. OTC pharmacy claims made up 13.99% of the total PPI claims submitted. The total cost to the medical schemes was R20 715 453,58, of which high-dose esomeprazole accounted for 30.08%. Two of the four medical schemes implemented an annual quantity limitation on PPIs of 90 tablets or capsules per year effective from 2023. Conclusion: Despite clear indications for safe use, PPIs are being overutilized on a long-term basis and for inappropriate indications. De-prescribing of PPIs in the elderly, especially high-dose esomeprazole, should be considered when re-evaluating patients to prevent overutilization. Authorized prescribers and pharmacists play an essential role in reducing PPI expenditure and discouraging PPI misuse by prescribing only according to national guidelines for appropriate indications and treatment duration, encouraging the use of cost-effective generics and alternative therapies, and educating patients on healthy lifestyle measures for the long-term management of acid-related disorders. The cost of PPIs to medical schemes in South Africa is currently very high and increasing steadily each year. The costs to medical schemes can be further reduced by implementing benefit design restrictions on PPI reimbursement.