Rising rates of proton pump inhibitor prescribing in US emergency departments

Published:March 24, 2014DOI:



      There have been mounting safety concerns over increasing prescription rates for proton pump inhibitors (PPIs). Trends in PPI use have not been studied in emergency departments (EDs). We characterize trends in PPI use in US EDs.


      We used data from the National Hospital Ambulatory Care Survey, from 2001 to 2010, focusing on encounters with a reason for visit with a potential indication for a PPI, histamine receptor (H2) blocker, or antacid. Patient, provider, visit, and hospital-level factors associated with increases in PPI use were evaluated.


      Among included visits, ED PPI prescribing more than doubled from 3.0 (95% confidence interval [CI]: 2.4-3.8) to 7.2% (95% CI: 6.3-8.3) from 2001 to 2010. Histamine receptor blocker use decreased from 6.8% (95% CI: 6.0-7.7) to 5.7% (95% CI: 4.9-6.7) and antacids from 7.2% (95% CI: 6.3-8.2) to 5.5% (95% CI: 4.8-6.3). Proton pump inhibitor prescribing was higher in males and whites yet increased across all demographics, including in adults aged 65 years and older. Proton pump inhibitor prescribing increased significantly in all US regions and across all hospital and payer types. Pantoprazole was the agent with the largest increase in use.


      Over the past decade, there have been considerable increases in PPI prescribing in US EDs. This trend occurred despite rising safety concerns, even in populations at higher risk for adverse events such as older adults. More education may be needed to ensure that ED providers are familiar with indications for PPIs.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Katz M.H.
        Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users.
        Arch Intern Med. 2010; 170: 747-748
        • Abraham N.S.
        Proton pump inhibitors: potential adverse effects.
        Curr Opin Gastroenterol. 2012; 28: 615-620
        • Vakil N.
        Prescribing proton pump inhibitors: is it time to pause and rethink?.
        Drugs. 2012; 72: 437-445
        • Famularo G.
        • Gasbarrone L.
        • Minisola G.
        Hypomagnesemia and proton-pump inhibitors.
        Expert Opin Drug Saf. 2013; 12: 709-716
        • Hoorn E.J.
        • van der Hoek J.
        • de Man R.A.
        • et al.
        A case series of proton pump inhibitor-induced hypomagnesemia.
        Am J Kidney Dis. 2010; 56: 112-116
        • Janarthanan S.
        • Ditah I.
        • Adler D.G.
        • et al.
        Clostridium difficile-associated diarrhea and proton pump inhibitor therapy: a meta-analysis.
        Am J Gastroenterol. 2012; 107: 1001-1010
        • Goodman S.G.
        • Clare R.
        • Pieper K.S.
        • et al.
        Association of proton pump inhibitor use on cardiovascular outcomes with clopidogrel and ticagrelor: insights from the platelet inhibition and patient outcomes trial.
        Circulation. 2012; 125: 978-986
        • Ramirez E.
        • Lei S.H.
        • Borobia A.M.
        • et al.
        Overuse of PPIs in patients at admission, during treatment, and at discharge in a tertiary Spanish hospital.
        Curr Clin Pharmacol. 2010; 5: 288-297
        • Forgacs I.
        • Loganayagam A.
        Overprescribing proton pump inhibitors.
        BMJ. 2008; 336: 2-3
        • Zink D.A.
        • Pohlman M.
        • Barnes M.
        • et al.
        Long-term use of acid suppression started inappropriately during hospitalization.
        Aliment Pharmacol Ther. 2005; 21: 1203-1209
        • Olbe L.
        • Lind T.
        • Cederberg C.
        • et al.
        Effect of omeprazole on gastric acid.
        Scand J Gastroenterol Suppl. 1986; 118: 105-107
        • Centers for Disease Control and Prevention
        Ambulatory health care data.
        ([Accessed July 26, 2013])
        • Kaiser Family Foundation
        Follow the pill: understanding the U.S. commercial pharmaceutical supply chain.
        ([Accessed November 22, 2013])
        • IMS Institute for HealthCare Informatics
        The use of medicines in the United States: review of 2010.
        ([Accessed November 22, 2013])
        • Choosing wisely
        Treating heartburn and GERD.
        ([Accessed October 10, 2013])
        • Yang Y.X.
        • Metz D.C.
        Safety of proton pump inhibitor exposure.
        Gastroenterology. 2010; 139: 1115-1127
        • Reimer C.
        Safety of long-term PPI therapy.
        Best Pract Res Clin Gastroenterol. 2013; 27: 443-454
        • Bhatt D.L.
        • Cryer B.L.
        • Contant C.F.
        • et al.
        Clopidogrel with or without omeprazole in coronary artery disease.
        N Engl J Med. 2010; 363: 1909-1917
        • García Rodríguez L.A.
        • Johansson S.
        • et al.
        Use of clopidogrel and proton pump inhibitors after a serious acute coronary event: risk of coronary events and peptic ulcer bleeding.
        Thromb Haemost. 2013; 110: 1014-1024
        • Huang B.
        • Huang Y.
        • Li Y.
        • et al.
        Adverse cardiovascular effects of concomitant use of proton pump inhibitors and clopidogrel in patients with coronary artery disease: a systematic review and meta-analysis.
        Arch Med Res. 2012; 43: 212-224
        • Tanguay J.F.
        • Bell A.D.
        • Ackman M.L.
        • et al.
        Focused 2012 update of the Canadian cardiovascular society guidelines for the use of antiplatelet therapy.
        Can J Cardiol. 2013; 29: 1334-1345
        • Mehta S.K.
        • Frutkin A.D.
        • Lindsey J.B.
        • et al.
        Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the national cardiovascular data registry.
        Circ Cardiovasc Interv. 2009; 2: 222-229
        • Ngamruengphong S.
        • Leontiadis G.I.
        • Radhi S.
        • et al.
        Proton pump inhibitors and risk of fracture: a systematic review and meta-analysis of observational studies.
        Am J Gastroenterol. 2011; 106: 1209-1218
        • Janarthanan S.
        • Ditah I.
        • Adler D.G.
        • et al.
        Clostridium difficile-associated diarrhea and proton pump inhibitor therapy: a meta-analysis.
        Am J Gastroenterol. 2012; 107: 1001-1010
        • Chitnis A.S.
        • Holzbauer S.M.
        • Belflower R.M.
        • et al.
        Epidemiology of community-associated clostridium difficile infection, 2009 through 2011.
        JAMA Intern Med. 2013; 173: 1359-1367
        • Linsky A.
        • Gupta K.
        • Lawler E.V.
        • et al.
        Proton pump inhibitors and risk for recurrent Clostridium difficile infection.
        Arch Int Med. 2010; 170: 773-778
        • Leontiadis G.I.
        • Sharma V.K.
        • Howden C.W.
        Proton pump inhibitor therapy for peptic ulcer bleeding: cochrane collaboration meta-analysis of randomized controlled trials.
        Mayo Clin Proc. 2007; 82: 286-296
        • Yeh K.C.
        • Chremos A.N.
        • Lin J.H.
        • et al.
        Single-dose pharmacokinetics and bioavailability of famotidine in man. Results of multicenter collaborative studies.
        Biopharm Drug Dispos. 1987; 8: 549-560
        • Reimer C.
        • Sondergaard B.
        • Hilsted L.
        • et al.
        Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy.
        Gastroenterology. 2009; 137 (87e1): 80-87
        • Lodrup A.B.
        • Reimer C.
        • Bytzer P.
        Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibitor treatment.
        Scand J Gastroenterol. 2013; 48: 515-522
        • van Marrewijk M.
        • Mujakovic S.
        • Fransen G.A.
        • et al.
        Effect and cost-effectiveness of step-up versus step-down treatment with antacids, H2-receptor antagonists, and proton pump inhibitors in patients with new onset dyspepsia (DIAMOND study): a primary-care-based randomized controlled trial.
        Lancet. 2009; 373: 215-225
        • Meltzer A.C.
        • Pierce R.
        • Cummings D.A.
        • et al.
        Rapid (13)C urea breath test to identify helicobacter pylori infection in emergency department patients with upper abdominal pain.
        West J Emerg Med. 2013; 14: 278-282
        • Mason J.M.
        • Raghunath A.S.
        • Hungin A.P.
        • et al.
        Helicobacter pylori eradication in long-term proton pump inhibitor users is highly cost-effective: economic analysis of the HELPUP trial.
        Aliment Pharmacol Ther. 2008; 28: 1297-1303
        • McCaig L.F.
        • Burt C.W.
        Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers.
        Ann Emerg Med. 2012; 60: 716-21.e1