Compliance with restrictions on the subsidized use of proton pump inhibitors in Australia

Aims: To determine among a cohort of patients newly dispensed a prescription for a proton pump inhibitor (PPI) the extent of prior use of other less expensive agents such as antacids and H₂-receptor antagonists as evidence of a 'stepped care' approach to peptic ulcer and oesophageal disease. Methods: A retrospective drug utilization study was conducted within the Pharmaceutical Benefits Scheme (PBS) claims database in Australia. A cohort of social security recipients, who received approval for PPI supply in the month of October 1996, had no prior PPI approval in the previous 18 months and went on to have the drug dispensed, was assembled. This group of 'new PPI starters' was then examined for supply of less expensive prescription medicines to treat peptic ulcer and oesophageal disease in the 12 months prior to obtaining their PPI approval. Results: In a cohort of 4554 defined new PPI users, 1205 (26.5%) showed no use of H₂-receptor antagonists, antacids, cisapride, cytoprotectants or antiregurgitants in the 1.2 month period prior to commencing the PPI. The major reason for use given by prescribers for PBS supply was 'severe refractory ulcerating oesophagitis'. Conclusions: Subsidized supply is currently restricted on cost-effectiveness grounds to refractory peptic ulcer disease or severe oesophageal disease. Despite this, utilization and epidemiological data suggest that there is widespread leakage of use outside these indications particularly to less severe forms of oesophageal disease. This patient tracking study has shown within the PBS database that around a quarter of the patients are treated directly with a PPI without being prescribed less expensive agents at least in the preceding 12 months.