New prescriptions and renewals of “antacid” medications, used in particular to treat gastric reflux and heartburn, continue to increase in Quebec, despite measures put in place by the government to promote better use of these drugs. this. According to a recent Quebec study, these treatments are used inappropriately in at least one out of two cases.
Nearly one million people on Quebec drug insurance have taken proton pump inhibitors (PPIs) — commonly known as “antacids” — in the past year, according to the Régie de l’assurance maladie du Québec (RAMQ). Between 2018 and 2022, the number of new prescriptions and refills for these drugs increased from 11,268,558 to 12,882,823, according to the RAMQ. This is an increase of almost 15%.
However, according to a Quebec study published in May in the Journal of the American Pharmacist Association, 49% of PPI prescriptions are “inappropriate”. This percentage even reaches 81% when “strict” criteria such as those of the RAMQ are applied with respect to the medical indications that may justify these treatments.
Patrick Viet-Quoc Nguyen, lead author of this study and a researcher at the Center de recherche du Center hospitalier universitaire de Montréal (CHUM), reviewed the records of some 1,500 patients taking PPIs and presenting to the emergency department of CHUM for any reason between 2019 and 2021. The team asked patients about their PPI intake and their current symptoms.
The researchers found that many patients took PPIs even though they no longer needed them. “And it’s worse than before,” says Patrick Viet-Quoc Nguyen. The latter conducted the same study in 2016 and 2017 with approximately 870 emergency patients at the CHUM. At the time, 30.7% of prescriptions were “inappropriate”. This percentage reached 76% with the RAMQ criteria.
For Patrick Viet-Quoc Nguyen, this is a sign that the measures put in place in 2017 by Quebec to “improve the long-term use of this class of drugs” are ineffective. For the past six years, the government has limited the reimbursement period for PPIs to a maximum of 90 days per year per insured person. For a longer period, physicians must enter a RAMQ exception code associated with a specific indication.
Patrick Viet-Quoc Nguyen believes that these codes for PPIs should be abolished. “The codes just increase the bureaucratic heaviness, it doesn’t really improve the appropriate prescription, he judges. Doctors don’t necessarily have time to reassess all prescriptions [auparavant prescrites]. They will just put a code automatically. »
The DD Mélanie Bélanger, president of the Association des gastro-enterologues du Québec, agrees with this “hypothesis of trivialization of the registration of a code” and a “habit of automatic renewal” without re-evaluation. “At first, everyone was afraid of hefty fines if unscrupulous prescriptions were made, but over time the fear lessened because no one heard of anyone being accused of indulging in prescribing. “, she remarks.
The DD Bélanger points out that the patients questioned in the context of this study – in the emergency room – are part of “the quasi-general population, only a minority of whom have already seen a gastroenterologist”. ” [Les chercheurs] have therefore mainly captured patients who have had their prescription from a general practitioner or another doctor who is less familiar with the treatment of digestive problems,” she says. According to the specialist, these doctors have “potentially more difficulty in explaining to patients that they will still evolve well without these drugs” and “more difficulty in proposing” other solutions.
A “success”, according to Quebec
The MSSS, for its part, considers the requirements put in place in 2017 a “success”. He recalls that these measures, implemented following recommendations from the National Institute of Excellence in Health and Social Services (INESSS), were particularly aimed “to limit the duration of reimbursement of PPIs” per patient, durations which were “much higher to good clinical practice” and which “generated unjustified costs”.
“PPI drug cost per patient was $104 in 2016 (calendar year) and is now $72 in 2022 (calendar year) in the public drug plan,” an email said. The MSSS specifies that the overall cost of these medications is not a good indicator, “since demographic changes can influence the number of people who need PPIs”.
Despite everything, Patrick Viet-Quoc Nguyen expresses “a doubt about the good clinical use” of PPIs. He believes that other means could improve their use. “For example, if we paid doctors and pharmacists to do ‘deprescribing’, to reassess [la pertinence d’un médicament], he says. It takes time. »
Patrick Viet-Quoc Nguyen recognizes that PPIs do not generate “a lot of adverse effects” and that they are “generally very well tolerated by people”. But he points out that some studies have shown, among other things, that their chronic use decreases the absorption of calcium and magnesium. “It possibly increases the risk of osteoporosis. »