Acid-Decreasing Drug Use in Veterans With GERD With/out Barrett's Esophagus
Acid-Decreasing Drug Use in Veterans With GERD With/out Barrett's Esophagus
Aim: To examine use of acid-decreasing medications, especially proton pump inhibitors (PPIs), in patients with gastro-oesophageal reflux disorder (GERD) with and without Barrett's oesophagus (BO) in a large-scale study.
Methods: We conducted a retrospective cohort study of patients with newly diagnosed BO (ICD-9 code 5302) and patients with GERD and no BO (ICD-9 53081, 5301) in Department of Veterans Affairs (VA) databases. Filled prescriptions for oral PPI and histamine2-receptor antagonists (H2RA) were identified in the VA Pharmacy Benefit Management database during 365 days following diagnosis. Groups with or without PPI or H2RA were compared in unadjusted and adjusted regression analyses. Chart review was used to validate diagnoses in a subset of patients with and without BO.
Results: We evaluated 7732 patients with BO and 13 457 with GERD and no BO diagnosed between 1/2000 and 12/2002. At least one PPI prescription was filled during the first year following diagnosis in 91.5% of BO and 61.4% of non-BO patients (P < 0.0001), and one H2RA in 31.7% of BO and 59.4% of non-BO patients (P < 0.0001), respectively. However, 6.1% of BO patients were prescribed neither. Median duration for PPI filled prescriptions was twice as long for BO (221.7 vs. 106.9 days) compared with non-BO patients. The ratio of PPI or H2RA filled prescription days to available follow-up days among BO subjects was 0.66 (122.8 days were not covered with prescription for either), and 0.55 in GERD patients with no BO (165.0 days on neither).
Conclusions: Veterans Affairs patients with BO are 50% more likely to be prescribed a PPI than patients with GERD and no BO. However, on average, PPI prescriptions cover only 60% of follow-up time for BO patients.
Barrett's oesophagus (BO) is the precursor lesion for oesophageal adenocarcinoma and is thought to arise as a complication of chronic gastro-oesophageal reflux disease (GERD); oesophageal adenocarcinoma is rapidly increasing in the US. Both the severity and duration of GERD symptoms (heartburn, regurgitation) have been shown to increase significantly the risk of developing BO. Furthermore, the risk of oesophageal adenocarcinoma is greatly increased with longer duration and greater frequency of heartburn or regurgitation.
Several guidelines and expert opinions have recommended the use of proton pump inhibitors (PPI) in patients with BO. Although studies have shown that regular, once-a-day dosing of PPIs is insufficient to achieve complete extinction of oesophageal acid exposure in most patients, recent evidence from two retrospective studies has shown that patients with BO who use PPIs are approximately 50% less likely to develop dysplasia compared with patients not on acid-suppressing medications. Therefore, several authorities recommend the use of PPIs, irrespective of the presence of GERD symptoms in patients with BO.
The actual extent of prescribing PPIs for patients with BO remains unknown, and no large-scale studies examine the extent and/or the determinants of PPI use in patients with BO. The aim of this study was to examine data from the Department of Veterans Affairs (VA) to determine the extent of PPI use in patients with newly diagnosed GERD with and without BO and to examine other potential determinants of PPI use in these patients.
Aim: To examine use of acid-decreasing medications, especially proton pump inhibitors (PPIs), in patients with gastro-oesophageal reflux disorder (GERD) with and without Barrett's oesophagus (BO) in a large-scale study.
Methods: We conducted a retrospective cohort study of patients with newly diagnosed BO (ICD-9 code 5302) and patients with GERD and no BO (ICD-9 53081, 5301) in Department of Veterans Affairs (VA) databases. Filled prescriptions for oral PPI and histamine2-receptor antagonists (H2RA) were identified in the VA Pharmacy Benefit Management database during 365 days following diagnosis. Groups with or without PPI or H2RA were compared in unadjusted and adjusted regression analyses. Chart review was used to validate diagnoses in a subset of patients with and without BO.
Results: We evaluated 7732 patients with BO and 13 457 with GERD and no BO diagnosed between 1/2000 and 12/2002. At least one PPI prescription was filled during the first year following diagnosis in 91.5% of BO and 61.4% of non-BO patients (P < 0.0001), and one H2RA in 31.7% of BO and 59.4% of non-BO patients (P < 0.0001), respectively. However, 6.1% of BO patients were prescribed neither. Median duration for PPI filled prescriptions was twice as long for BO (221.7 vs. 106.9 days) compared with non-BO patients. The ratio of PPI or H2RA filled prescription days to available follow-up days among BO subjects was 0.66 (122.8 days were not covered with prescription for either), and 0.55 in GERD patients with no BO (165.0 days on neither).
Conclusions: Veterans Affairs patients with BO are 50% more likely to be prescribed a PPI than patients with GERD and no BO. However, on average, PPI prescriptions cover only 60% of follow-up time for BO patients.
Barrett's oesophagus (BO) is the precursor lesion for oesophageal adenocarcinoma and is thought to arise as a complication of chronic gastro-oesophageal reflux disease (GERD); oesophageal adenocarcinoma is rapidly increasing in the US. Both the severity and duration of GERD symptoms (heartburn, regurgitation) have been shown to increase significantly the risk of developing BO. Furthermore, the risk of oesophageal adenocarcinoma is greatly increased with longer duration and greater frequency of heartburn or regurgitation.
Several guidelines and expert opinions have recommended the use of proton pump inhibitors (PPI) in patients with BO. Although studies have shown that regular, once-a-day dosing of PPIs is insufficient to achieve complete extinction of oesophageal acid exposure in most patients, recent evidence from two retrospective studies has shown that patients with BO who use PPIs are approximately 50% less likely to develop dysplasia compared with patients not on acid-suppressing medications. Therefore, several authorities recommend the use of PPIs, irrespective of the presence of GERD symptoms in patients with BO.
The actual extent of prescribing PPIs for patients with BO remains unknown, and no large-scale studies examine the extent and/or the determinants of PPI use in patients with BO. The aim of this study was to examine data from the Department of Veterans Affairs (VA) to determine the extent of PPI use in patients with newly diagnosed GERD with and without BO and to examine other potential determinants of PPI use in these patients.