title: Proton pump inhibitors: Are we still prescribing them without valid indications?
abstract: BACKGROUND
  Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia.
  
  
  OBJECTIVE
  We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore.
  
  
  METHODS
  We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as "valid", "likely invalid", and "probable" based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected.
  
  
  RESULTS
  From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as "likely invalid"); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was "probable". The most common "likely invalid" indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions.
  
  
  CONCLUSIONS
  Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.
authors.affiliation: University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore.
authors.forename: Farooq
authors.initials: F
authors.lastname: Akram
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore.
authors.forename: Yufang
authors.initials: Y
authors.lastname: Huang
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore.
authors.forename: Valencia
authors.initials: V
authors.lastname: Lim
authors.affiliation: Waikato District Health Board, Hamilton, New Zealand.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Huggan
authors.affiliation: University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore.
authors.forename: Reshma A
authors.initials: RA
authors.lastname: Merchant
keywords: Proton pump inhibitors; elderly; prescribing; valid indications