Adherence to PPIs: Always Ask

By some estimates, up to 50% of patients with gastroesophageal reflux disease do not take proton pump inhibitors as prescribed and may benefit from counseling to improve adherence, according to a recent review.

Proton pump inhibitors (PPIs) are the go-to class of drugs when patients present with gastroesophageal reflux disease (GERD) and for the majority of patients, they effectively block gastric acid secretion. In approximately 40% of patients, however, these drugs resolve reflux complaints only partially. Therapeutic failure has been primarily associated with a handful of factors: non-acid or weakly acid reflux, genotypic differences, comorbidities, wrong diagnosis, and treatment nonadherence.

A review of research on patients’ adherence to PPI therapy was published online on April 22, 2014, in Expert Review of Gastroenterology and Hepatology. Many studies have looked at adherence rates in various nations, and some have reported rates approaching 80%. These studies may not have examined time of day (PPIs are best taken in the morning) or relationship to food (many PPIs should be taken on an empty stomach). By missing this data, studies may artificially inflate adherence rates. Other studies indicate that up to 50% of GERD sufferers do not take their PPI therapy as prescribed.

In GERD, severe symptoms usually prompt patients toward complete adherence since their discomfort is great. Patients who have mild to moderate GERD may become nonadherent, and symptoms may recur. When patients report breakthrough symptoms, clinicians should always ask directly and specifically about adherence.

The authors describe many factors that may adversely affect adherence to PPIs. These include general adherence issues such as social and demographic factors, financial pressures, poor understanding of their prescription or incomplete disease awareness, and poor relationship between the patient and health care provider. They also note that some factors are specific to the PPI class. For example, medication side effects; breakthrough symptoms or GERD complications; PPI frequency; polypharmacy for GERD; or comorbidities can reduce PPI adherence.

The authors suggest clinicians should discuss the need for total adherence with patients and repeat the discussions as needed. Thorough counseling must emphasize the need for early-morning dosing, and depending on the dosage form, the importance of taking the PPI on an empty stomach.

If patients improve adherence but continue to have GERD symptoms, increasing the PPI dose or switching to a different PPI may be a reasonable action. After 4 to 8 weeks, patients who remain unimproved may be better diagnosed with refractory GERD. The causes of treatment failure may be elusive and fundoplication surgery may be indicated.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.