Gastric acid secretion is an inherent physiological function of the human body. It is associated with many physiological activities. Only when it is necessary to prevent and treat certain digestive diseases, it is necessary to increase the pH value in the stomach. PPIs is a relatively safe type of acid suppression preparations, but overuse can also cause electrolyte metabolism disorders such as calcium and magnesium , and increase the risk of infection and other adverse consequences , which should be paid enough attention. Indications for the use of drugs for digestive tract gastric acid-related diseases are not accurate enough, which may lead to therapeutic abuse of PPIs . Fear of gastrointestinal bleeding, lack of attention to side effects of acid suppression, and unfamiliar indications for emergency ulcer prevention are the main causes of preventive abuse of PPIs . The development of PPIs clinical drug standards, strict control of preventive drug indications, strict implementation of special prescription review system and other interventions can effectively reduce the use of PPIs, improve the rational use of PPIs, save resources, and reduce medical costs and risks .
In this study, the average use rate of PPIs before intervention was 27.05%, which was basically consistent with the literature reports ; irrational use of drugs was 47.60%, higher than reported in the literature (34.00%) . Among the patients with irrational use of drugs, 65.60% of the drugs were not indicated, and the preventive drug was not suitable for 22.02%, indicating that the clinical drug indications were not well mastered. After the intervention, the average utilization rate of PPIs was 8.54%, and the total ratio of irrational medication was 31.84%. After the intervention, the average use rate and irrational drug use ratio of PPIs decreased significantly (P<0.05). Among the patients with irrational medication, the preventive medication was not suitable for 50.88%, and the indication was 45.61%, indicating that the rationality of clinical medication was improved after the intervention of clinical pharmacists.
Preventive overuse of PPIs is a worldwide problem . In this study, the top 5 departments with the average pre-intervention rate, except for the department of gastroenterology, were mostly preventive PPIs. In addition, there are also indications, super-instructions, such as diagnosis of knee arthritis, cervical spondylosis, treatment with injection of omeprazole. After the intervention, the average utilization rate of the department was reduced by nearly 50%, and the average use rate of the spine joint surgery decreased by 93.78% dramatically.
Before and after the intervention, the PPIs used involved five varieties of specifications, the highest frequency of use was omeprazole for injection, followed by pantoprazole for injection. Omeprazole is the first generation of PPIs, which is characterized by large differences in the bioavailability of the drug, and is susceptible to food or other drugs. Pantoprazole is a third-generation PPIs drug. Compared with omeprazole, pantoprazole has high bioavailability and remains stable, independent of food intake and antacids, through cytochrome P450 enzymes. Other drugs that metabolize have less interaction than omeprazole, and pantoprazole is superior to omeprazole in terms of safety and efficacy. The results of the survey showed that the frequency of use of the first-generation PPIs was the highest, both before and after the intervention, and the third-generation PPIs with higher efficacy and safety were only half the former. It shows that most of the time clinicians choose drugs according to their habits, and there are still insufficient concerns about the safety and effectiveness of drugs. Clinical pharmacists should increase their medical advice and prescription comments in this regard and make proper guidance.
In addition, the average use rate of PPIs was 94.3% before the intervention, which was significantly higher than that reported in the literature (43.24%) . For inpatients, the medication is well compliant, making physicians more inclined to use injections. Studies have shown that gastric juice pH> 4 can achieve the purpose of preventing stress ulcers , most PPIs oral preparations were given the usual amount, gastric juice within 24h of 90% of patients can reach this pH, if administered half an hour before breakfast and dinner, the ratio of pH in the stomach will be higher . For patients without oral disorders, elective surgery, and indications for prevention of stress ulcers, oral medications can be used for prevention purposes. For postoperative patients, once enteral nutrition is acceptable, preventive use of PPIs should be discontinued . Compared with oral administration, the intravenous administration process is more complicated, requiring open venous access, nursing manual care, increasing medical safety risks and medical costs, and oral administration is convenient to use, reducing labor costs and saving medical resources. Excessive use of injections not only increases the medical burden and medical risks, but also increases the workload of clinical treatment and increases the economic burden of patients, which should be taken seriously.
The age and gender distribution of patients before and after intervention were similar (P>0.05). After the intervention, the use rate of PPIs was greatly reduced, and the reasonable rate was significantly increased (P<0.05). There was no significant difference in the average length of stay, cure rate and mortality (P>0.05), indicating that the significant reduction in the use of PPIs in inpatients after intervention did not affect the patient’s treatment effect.
The intervention of clinical pharmacists promotes the rational use of PPIs, but there are still problems such as insufficient mastery of medication indications and irrationality of drug selection. In the future work, clinical pharmacists should strengthen the training of relevant knowledge and skills of clinicians and improve the rational use concept of clinicians; conduct regular special investigations, increase the evaluation of relevant doctors, and make timely feedback of problems to improve medical safety and reduce medical risks. Constrained by the research methods, this survey failed to evaluate the clinical course of treatment and adverse reactions of PPIs and needs further investigation.
One of major limitations of this study was the results still retained sufficient statistical power to evaluate the presence of any sub-group differences among the various factors for improvement the level of PPIs rational clinical medication given the rather large sample size. Secondly, due to the selected study subjects are based on the volunteers, the potential selection bias is inevitable because the participants who made a roust decision to be in the study hospitals. Voluntary bias could be viewed as the fact that a special sample could contain only those study subjects who are totally willing to join to the investigation and who participate and find the topic specially interesting are much possible of one’s own free for that study, same to those who are look forward to be estimated on a positive level . Thirdly, the generalization and external validity for the results should be further discussed. Finally, this study only obtained subjects from one teaching hospital in China as the target population. Therefore, the results of this study should not be extrapolated to hospitals in other regions of China. Future studies with random sampling approach of hospital selection over a wider range of regions would make the study more representative.