Prescribing Practices and Cost of Drugs for Peptic Ulcer Disease - Coursework Example

Evaluating Prescribing Practices and Cost of Drugs for Peptic Ulcer Disease Ali Saleh Alkhoshaiban. Research Paper Dean-Michal Lynn November 12, 2011 Abstract Differences in prescribing patterns for anti-ulcer drugs have been a debate among researchers and clinicians. Controlling the cost and improving the quality of prescribing is an issue of concern to many clinicians and patients. The clinical guideline programmers, as being developed in many countries, contribute to the quality of care in general practice. Introduction The use of proton pump inhibitors differs between gastroenterologists and primary care physicians. Although most physicians believe that proton pump inhibitors are safe, few believe that they should be available without a prescription (Barrison, 2001). For many years, the medical community has been treating the peptic ulcer in a variety of ways; however, there should be a uniform standard for the prescribing patterns for the treatment of peptic ulcers, which need certain considerations including prescriptions standard guidelines and cost effectiveness of the drugs and dosages. Discussion According to Ren and Lee, “The choice of agent was associated with patients’ co-morbid condition and was correlated with cost reduction in inpatient medical /surgical or psychiatric care” (Ren and Lee, 2006). However, the distinctive patterns: in co-morbidity, healthcare utilization, and cost reduction between patients prescribed olanzapine versus risperidone imply that each drug may be useful for patients with definite co-morbid conditions, at least among patients with severe medical or psychiatric conditions. Antacid prescriptions, to heal ulcers or to alleviate the dyspepsia caused by other drugs were common in Taiwan in the year 2000. There was widespread belief in Taiwan that western drugs used for stomach treatment were harmful. Both qualitative and biochemical analyses are required to conclude whether the habit of prescribing antacids in Taiwan is based on such perceptions or whether it is conditioned by the acidity of other drugs (Chen, 2003). This prompts us to criticize the criteria used in antacid prescriptions in Taiwan and as such propose rigorous and comprehensive research on the actual medical reason behind such a widespread belief According to Montanaro, there exist two major problems in drug prescription. Most prevalent is the habit of over prescription of well-documented drugs, such as H2-antagonists, ACE-inhibitors, and calcium antagonists. Secondly, comparison to other countries like Sweden, where the ratio of older to newer drugs within gastrointestinal (antacids vs. H2-antagonists) and cardiovascular (beta blockers vs. ACE-inhibitors and calcium antagonists) is largely in favors of the older preparations (Montanaro, 1992). These are certainly two factors that need to be recalled when determining the differences in preference when doing a prescription. This will be very important in setting uniform standards for the prescribing patterns for the treatment of peptic ulcers. Moreover, in 1989, the HMG-CoA-reductase inhibitors became the most frequently prescribed antihyperlipidaemics. There is observed large-scale prescription of drugs of uncertain efficacy, such as mucolytics and common cold-preparations. Additionally, frequent prescription of drugs that lack documented clinical efficacy such as those prescribed for clinical conditions with no specific treatment is also a common phenomenon. For example, dementia or placebos for minor disorders metabolic supplements and hepatic protectants. According to Montanaro Prescription of drugs of controversial effectiveness, which are often prescribed for indications other than those for which some evidence of efficacy, is available; for example, calcitonin showed a marked increase in prescriptions (1992). Whereas this is unexpected, it presents a new ground of research into why drugs of controversial effectiveness win over drugs with evidenced efficacy. Perhaps other factors such as cost and availability may be the moving factors. The widespread use of peptic ulcer drugs are mostly due to excessive prescription for non-ulcer dyspepsia and many patients devour these drugs on long-term basis in the absence of clear diagnosis. Ranitidine is the most broadly used in the treatment of gastro-duodenal ulcer. Other drugs are also increasingly being used. This study found no direct relationship between the mean daily doses of either drug and the cruelty of the pathology (Morales, 1998). It is therefore safe to conclude that cost is an important factor when it comes to prescription of ulcer drugs especially when drugs are to be taken on long-term basis. The utilization of ulcer-healing drugs for treatment of gastric protection in the cirrhotic patient ware notably higher than expected at discharge from hospital, 35% compared with 24% on admission. In this study, unforeseen finding was the prevalent practice of prescribing anti-ulcer drugs for ‘gastric protection’’ in patients with liver disease. An evidence-based approach of the efficacy of this class of drugs in liver diseases shows that the only verified indications are the uses of anti H2-receptor antagonists to prevent stress ulcers in patients with severe liver failure and the use of proton-pump inhibitors as prophylaxis of esophageal ulcers and strictures after sclera-therapy (Lucena, 2002). Higher percentage of use of ulcer-healing drugs for treatment of gastric protection in the cirrhotic patient during discharge suggests that it was caused by diagnosis of ulcers and other related conditions. Breuer conducted a survey investigating prevalence of prescription of H. pylori therapy for non-ulcer dyspepsia among primary care physicians and gastroenterologists. Approximately 40 to 70 percent of primary care physicians did the prescription as compared to30 to 40 percent of gastroenterologists. Additionally, this prescribing pattern was time independent (Breuer, 1998). These results indicates that primary care physicians are more inclined to prescribing H. pylori therapy for non-ulcer dyspepsia as compared to gastroenterologists. Actually, physician knowledge of the etiological roles of H.pylori-associated diseases is well developed in Germany. In spite of that, a considerable proportion of family practitioners do not treat diagnosed H. pylori infection in the first presentation of duodenal ulcer disease and use less efficient or useless regimens to treat the infection. The responses of United States and German physicians concerning knowledge about etiological roles of H.pylori-associated diseases were similar in both countries. However, large differences were observed in the specific therapeutic regimens prescribed. A large proportion of German gastroenterologists recommended H.pylori regimens. Approximately, half of both physician groups used dual therapy containing amoxil and omeprazole. PPI/AMO was highly recommended in German literature whereby recommendations of the majority of guidelines and reviews recommended PPI first line eradication therapy. The rest of the published studies used H2- antagonist. According to Miren, a wide variation for PPIs used by the GPs, and 23-fold differs between the highest and lowest users. Besides that, only fund-holding status and membership/fellowship of the RCGPs were significant. Additionally, it only explained 23% of the variation in total PPIs prescribed. The dose of PPIs should be given in range, according to the guidelines. Fund holders were likely to prescribe fewer PPIs, as compared to RCGP members who were likely to prescribe slightly more (Miren, 2001). Despite the variation of PPIs used by the GPs, and 23-fold among highest and lowest users, it is important that a set standard of guidelines be followed. The most frequent antiulcer drugs prescribed as monotherapy and combination therapy is H2-receptor inhibitor (83% - 85%). PPI is less frequent antiulcer drugs as monotherapy as well as combination therapy (17% - 14 %). Other studies such as Breuer in 1998 showed similar results for H2 antagonists (69%- 12%) and for PPIs (7%) as monotherapy (Breuer, 1998). This results indicate that H2-receptor inhibitor is more commonly preferred as compared to PPIs. This seems to correlate with the lowest and highest users as suggested by Miren. The GPs cost data for lansoprazole and total PPI prescribing were compared with data for Birmingham Health Authority, the west Midlands regions and England from Jan1995 to Sept 1997. Consequently, the total cost of PPI prescribing GPs was higher than in the west midlands region and England. However, the cost of lansoprazole prescribing was similar (Miren, 2001). This indicates the variability in regional preference when it comes to using cost as a contributing factor. Naunton claims, while the proton pump inhibitors are effective agents, and studies indicate consistently excessive use before endoscopy, use in patients who do not fit the criteria is not advisable. Instead, less powerful agents enough to the symptoms of the patient should be used (Naunton, 2000). This raises fears of an economic and safety, particularly in light of the suggestion that these drugs may delay the diagnosis of gastric cancer, It is claimed that there is over utilization of proton pump inhibitors without an adequate trial of H2-antagonists. The cost-effectiveness of such changes in prescribing remains unclear. Concern has been expressed that many patients may be being treated with these expensive drugs without having tried life-style modification or better still, less expensive treatments (Naunton, 2000). Measures should be taken to influence medical practitioners to prioritize safer measures first before going to more complex and expensive treatments. Naunton found out that an appreciable number of patients were using proton pump inhibitors as a form of treatment for unlicensed indications of non-ulcer dyspepsia and nonspecific abdominal pain (Naunton, 2000). In spite of proton pump inhibitor being a viable option for patients, it is certainly not the best option. This is because it predisposes the patients to heart complications as well as heartburns. Specifically, studies conducted in 1998 revealed that prescriptions for proton pump inhibitors amounted to two million. All these proton inhibitors were dispensed through community pharmacies across Australia and it cost the government almost 200 million dollars. In particular, Omeprazole ranked among the highest in pharmaceutical benefits in 1998. Consequently, total PPIs prescriptions increased continually from 1990 to 1996. However, the use of H2-antagonists did not decrease correspondingly (Naunton, 2000). This study reveal that although use of proton pump inhibitors is increasing its impact on H2-antagonists is relatively insignificant. It gives a signal that more preference is given to proton pump inhibitors. Dr. Daneil H claimed that the cost of COX-2 inhibitor is a great contributing factor discouraging their use (Daneil, 2003). This does not come by surprise since its price is up to 20 times higher than the alternative Ibuprofen. An issue of concern is raised as to whether rofecoxib may be associated with escalated risk of myocardial infarction. Consequently, a deeper understanding of how these agents are utilized in typical medical practice and whether such use is optimized. Conclusion The majority of patients were using Ranitidine (Zantac), while only few others using Omeprazole (Losec). This pattern is inconsistent with the most of the guidelines. The only rationale of such prescribing pattern is the cost burden of PPIs. Someone could consider PPIs for only recurrent cases when H2 antagonists were failed and the cost was an issue. After the rigorous discussion it is now evident that use of proton inhibitors differs between gastroenterologists and primary care physicians. Some of the underlying reasons were discussed with the most important being cost effectiveness, preference, dosage, conventional belief, and level of understanding that exist between these two groups. The most prevalent rationale of such prescribing pattern is the cost burden of PPIs. PPIs win over H2 antagonists mostly for recurrent cases. However, it is of utmost importance if a universal standard for prescription pattern was developed. References Barrison.A.F. JarboeL.A, Benjamin M. Weinberg.B.M,et al. Patterns of Proton Pump Inhibitor Use in Clinical Practice.Am J Med. 2001; 111:469–473 Breuer T, Sudhop T, Goodman KJ, Graham DY, Malfertheiner P. How do practicing clinician manage Helicobacter pylorirelated gastrointestinal diseases in Germany? A survey of gastroenterologists and family practitioners. Helicobacter 1998; 3: 1-8. Breuer T, Goodman KJ, Malaty HM, Sudhop T, Graham DY. How do clinicians practising in the U.S. manage Helicobacter pylori-related gastrointestinal diseases? A comparison of primary care and specialist physicians. Am J Gastroenterol 1998; 93: 553- 61. Chen.T.J, Chou.L.F, and Hwang.S.J. Application of a Data-Mining Technique to Analyze Co prescription Patterns for Antacids in Taiwan. Clinical Therapeutics, Volume 25, Number 9, September 2003, pp. 2453-2463(11). Daneil H Solomon, MD, MPH. Selbastain S, MD. Robert J, American Journal of medicine, volume115, cecember15, 2003. Lucena.M.I, Andrade.R. J, Tognoni.G, et al. Multicenter hospital study on prescribing patterns for prophylaxis and treatment of complications of cirrhosis. Eur J Clin Pharmacol (2002) 58: 435–440. Miren J, Sheila MG, Sue J, Proton pump inhibitor s: a study of GPs prescribing, Family practice2001; 18:333-338. Montanaro N, Magrini N, Vaccheri A, et al. Drug utilization in general practice: prescribing habits of National Formulary drugs by GPs of Emilia Romagna (Italy) in 1988 and 1989. Eur J Clin Pharmacol (1992) 42:401~40. Morales Suárez-Varela MM, Pérez-Benajas MA, Girbes Pelechano VJ, Llopis-González A. Antacid (A02A) and antiulcer (A02B) drug prescription patterns: Predicting factors, dosage and treatment duration. Eur J Epidemiol 1998; 14: 363-372. Naunton M, G. M. Peterson and M. D. Bleasel . Overuse of proton pump inhibitors, Journal of Clinical Pharmacy and Therapeutics (2000) 25, 333-340. Yu. W, Ren. X. S, Lee. A. F, Association of Co-Morbidities with Prescribing Patterns and Cost Savings Olanzapine versus Risperidone for Schizophrenia. Pharmacoeconomics 2006; 24 (12): 1233-1248. November 14: 2nd Draft Assignment Evaluation 100 points BONUS Points 5 Points for Early 2nd Draft Submission BONUS Points 10 Points for Abstract (one time/one draft only). Format and Appearance (10 points) 10 Including: title page, page numbers, margins around each page, word processing conventions, font size, spacing, etc. Documentation of sources in the text and Reference page (30 points) 28 In the text: appropriate format and location of citation; accurate information References: alphabetical order, full citation with correct format and punctuation All sources listed at the end should connect to all citations in the text. Organization, Content, Unity and Cohesion (30 points) 23 Including: effectiveness of introduction and thesis; organization and development of the body; connections between sections and use of transition words; effectiveness of the conclusion. Information/clarification requested in feedback from the first draft has been provided. Integrated paragraphs (Topic sentence + explanation + evidence + explanation + concluding sentence) Language Use (30 points) 25 Including: grammar, sentence structure, word order, word choice, vocabulary, punctuation, etc. Final 2nd Draft Score 86/100 = B Read More