Safety - Proton Pump Inhibitors

The increasing evidence relating to the potential consequences of long-term treatment with PPIs has led to their inclusion within the safety domain of the National Prescribing Indicators.

Examples of adverse effects include C.difficile infection, increased risk of bone fractures and vitamin B12 deficiency.

The aim of the indicator is to reduce inappropriate prescribing of PPIs, and to prevent patients receiving long term treatment without a clear indication.


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  • During the financial year 2019–2020, over 4.8 million prescriptions for PPIs were dispensed in Wales, this equates to approximately 11% of the population having been prescribed a PPI.
  • There is increasing evidence regarding the potential consequences of long-term treatment with PPIs, including C. difficile, infection, fractures and hypomagnesaemia.
  • Other possible serious adverse effects include acute interstitial nephritis, vitamin B12 deficiency and rebound acid hypersecretion.
  • When the potential adverse effects are taken into consideration, the possible risks of treatment may outweigh the potential benefits, particularly in patients without a clear indication for a PPI, or when the patient is at increased risk of medicine-related adverse effects.

Trend in proton pump inhibitor prescribing


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PPI DDDs per 1,000 PUs – Quarter ending December 2020 

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How can changes be made?

  • When initiating a PPI, only consider for short courses (4 weeks) where needed, using acute, rather than repeat, prescriptions.
  • Ensure that lifestyle advice is given along with advice on returning to self-treatment with antacid and/or alginate therapy.
  • Review the need for a further prescription if requested by the patient, and review long-term PPI prescriptions at least annually.
  • Inform patients of the potential long-term effects of PPIs as this may result in them being more willing to try self-care to improve their symptoms.
  • Use the AWMSG patient information leaflet ‘Stopping Your PPI’ when initiating; reducing and stopping PPIs.
  • Use the PPI audit and review toolkit in AWMSG Safe Use of Proton Pump Inhibitors resource pack.

Ranitidine supply disruption- please note 

Due to the disruption to the supply of ranitidine from October 2019 and the recommendation to switch to omeprazole, rather than an alternative H2-receptor antagonist where ongoing treatment is still required and the patient cannot be stepped down to an antacid or alginate, there may be a resultant increase in PPI prescribing.



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