The Pharmaceutical Journal Vol 263 No 7069 p710
October 30, 1999 Letters

GORD

Use of proton pump inhibitors

From Dr A. R. Maisey, MRCGP

SIR,—While researching for a presentation, I read with interest your special feature on gastro-oesophageal reflux disease (PJ, August 14, p241). The majority of the article was well researched and informative, with a clear overview of the problem and possible solution, particularly useful as we read that the National Institute for Clinical Excellence is to take an early focus on proton pump inhibitor usage.
However, I feel the statement "equipotent doses of differing PPIs are similar in overall efficacy" in Table 2 of the summary of evidence base for treatment is incorrect and may greatly influence the overall cost effectiveness of the conclusions concerning the rationalisation of prescribing.
My understanding of the research data published is that in maintaining a symptom-free state in GORD, the lower dose of 15mg lansoprazole is more effective than the 10mg dose of omeprazole.1 As the more effective product is also considerably cheaper than its rival, and now less expensive than the Drug Tariff for generic ranitidine, these costs should be taken into account when choosing an initial PPI and certainly in choice of maintenance therapy, where we should use the lowest effective dose. The majority of prescribing should be for maintenance therapy.
The pharmacological supervision of "step down" acid suppression is an excellent suggestion for cost control in this difficult area, but perhaps the regime should include the 15mg dose of lansoprazole now that there is no clear evidence of differing side effects between the PPI agents.2

A. R. Maisey
Princes Risborough, Buckinghamshire

References

Ms M. KINNEAR (Lothian pharmacy practice unit) replies: The article aimed to review GORD and its treatment with the intention of forming a basis for exploring opportunities for pharmaceutical care in this patient group. Critical analysis of the comparisons between individual proton pump inhibitors and H2-receptor antagonists was not within the scope of the article, neither was evaluation of cost effectiveness studies in this field. We acknowledge that cost-effective prescribing is important to pharmaceutical care but also recognise that cost-effectiveness extends beyond drug costs and cost-effectiveness data may only be relevant to the services provided within the geographical area where it was generated.1
The licensed indications and individual costs for all four proton pump inhibitors are continually changing as Dr Maisey has noted from the comment published in Prescriber. It is our opinion that the appropriate use of proton pump inhibitors is central to rationalising prescribing in GORD and that the choice and dose of the drug should follow local formulary recommendations.
Dr Maisey claims that our statement "equipotent doses of differing PPIs are similar in efficacy" is incorrect and states that "(my) understanding of the research data published is that in maintaining a symptom-free state in GORD the lower dose of 15mg lansoprazole is more effective than the 10mg dose of omeprazole" but does not provide any citation of the literature for us to respond to. Our interpretation is based on the evidence that similar dose-response relationships are displayed at the same milligram doses.2 Differences in efficacy are unlikely to be due to differences between the drugs and more likely to be the result of different licensed dose recommendations.
Dr Maisey also suggests that lansoprazole 15mg is not included in the proposed step-down strategy. The terminology used to express the doses of PPIs in the step-down recommendations was based upon that used in the "Genval" workshop report.3 Interpretation of these recommendations and reference to the licensed doses of the individual drugs does not exclude lansoprazole 15mg, which for many patients we agree is appropriate maintenance therapy and is supported by several studies including that of Baldi et al published in abstract form and referred to by Dr Maisey.

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