DISCUSSION
This study was performed to explore the current prevalence of
unnecessary GI medication use in outpatient prescriptions for the common
cold in Korea. We found that unnecessary GI medication use accounted for
43.80%. GI drugs have been routinely included in numerous prescriptions
to decrease GI symptoms such as heartburn, nausea, and dyspepsia in
Korea.16,17(17) Byeon et al. conducted a chart review
study of a large city hospital and discovered that 58.6% of patients
with the common cold who did not present with symptoms or a history of
GI diseases were prescribed GI drugs such as digestive enzymes, GI
mobility drugs, antacids, and acid-controlling
agents.15 Cho et al. conducted a study to analyse the
prescription behaviours of 148 office-based doctors using data from
standardized common cold patients in Korea.16 In this
study, approximately 80% of the doctors prescribed GI medicines (such
as H2-blockers and motility drugs) following analgesics and NSAIDs
(89.2%) to patients with the common cold. The prescription rate of
unnecessary GI medications in our study was lower than that in previous
studies, probably because of the differences in study designs.
The use of unnecessary GI drugs, such as when they are not indicated,
could lead to various detrimental outcomes such as adverse drug
reactions, drug interactions, and increased drug
expenditure.17 Especially, dopamine antagonists (i.e.,
domperidone and metoclopramide) are known to increase the risk of
extrapyramidal symptoms that generally manifest as acute dystonic
reactions and hyperprolactinemia, leading to gynecomastia and
impotence.25 PPIs increase the risk of bone
fractures,26-29 pneumonia,30-33Clostridium difficile infection,34,35 and
vitamin B12 deficiency.17,36,37
Therefore, deprescribing GI medications for colds would be worth the
outcome of reducing the risks of GI drug-related potential harm and
unnecessary medical expenses. Studies evaluating the effect of
deprescribing show its potential positive impact on improving health
outcomes.38-41 A review by Endsley suggests that
deprescribing, which involves instituting a set of interventions to
identify inappropriate or unnecessary medications and discontinue them,
contributed to improvement in cognition, fewer falls, reduced risk of
hospitalization, and improved survival.42 McGrath et
al. reported that PPIs are a common target of deprescribing because of
the few indications for long-term use; significant drug-drug
interactions with other commonly used medications; and increased risk of
bone fractures, pneumonia, Clostridium difficile infection, and
vitamin B12 deficiency.43
Variations in unnecessary GI medication prescribing related to
physicians’ specialties were identified in our study. The delivery
system of healthcare services in Korea is different from Western
countries.44 Doctors can run a private office
regardless of their specialty and patients can visit any specialists
directly on their own for mild diseases such as a
cold.44,45 Paediatricians were least likely to
prescribe unnecessary GI medications. It could be considered as a cause
that most GI drugs are not routinely prescribed to children. We found
that NSAID use was a strong predictor of unnecessary GI medication
utilisation (OR=1.903, 95% CI=1.648-2.199). NSAIDs effectively relieve
pain in headaches, myalgias, and arthralgias and the fever-related
discomfort experienced during a cold.2,7 NSAIDs
inhibit cyclooxygenase-1 and -2, converting arachidonic acid to
prostaglandins, and thereby exert antipyretic, analgesic, and
anti-inflammatory effects.46 However, these
prostaglandins also protect the gastric mucosa, and therefore, the
inhibitory actions of NSAIDs have adverse effects, mainly on the GI
tract.47 However, the majority of patients taking
therapeutic doses of NSAIDs for a shorter duration and who do not have
underlying GI disorder usually tolerate them well.48The concomitant use of GI medications such as mucosal protective agents,
H2 receptor antagonists, or PPIs has no rationale in the treatment of
the common cold.
Unlike a previous study15 where there was no
statistically significant difference between the prescription of GI
drugs and the number of cold drugs, we found that the group prescribed
three and more than four cold medicines received fewer GI drugs than the
group that was only prescribed one. It could be speculated that doctors
find it difficult to prescribe a single drug; therefore, they try to
increase the number by including unnecessary GI drugs in the
prescription.
This study has certain limitations. First, because the claims data are
primarily collected for the reimbursement of healthcare services and not
for clinical purposes, the diagnosis information could be susceptible to
up-coding by providers seeking a higher reimbursement
rate.23 A previous study that compared the designation
of diagnoses in HIRA data to the actual status of health conditions
based on medical record reports showed that an average of 70% of
diagnoses corresponded to those in the medical
charts.23Second, the claims data are not applicable to
research on healthcare services not covered by insurance or
over-the-counter drugs.49 Third, patients diagnosed
with the common cold who were included in our study could have
simultaneously had other conditions. In such cases, GI medications might
have been prescribed not only for the cold but also for other
conditions. Therefore, the relationship between GI drug use and a
specific disease should be carefully interpreted.19
Despite these limitations, the present study result has significant
implications. Compared to previous studies that analysed prescription
patterns in some medical institutions15,16, our study
targeted a much broader population group extracted from almost all
Korean populations. Therefore, the results could be generalized. In
addition, it is meaningful that our study also investigated the
influencing factors in comparison with the existing studies that only
calculated the prescription ratio15,16,50.
It is important to change the perception that adding GI medication to
symptom-relieving drugs for the common cold is beneficial or at least
not harmful in patients with the common cold. Shin et al. reported that
promoting public health campaigns and developing practical guidelines,
educational resources, and restrictive drug policy resulted in reducing
inappropriate prescriptions.19
Patel et al. conducted an observational, cross-sectional,
questionnaire-based study to assess the prescribing pattern of doctors
to patients presenting with the common cold.51 In that
study, the authors reported that inappropriate prescriptions by doctors
is due to a lack of adequate training, lack of self-confidence, or
both.51 Hence, it would be expedient to address this
issue by emphasizing the need for proper training of prescribers during
their formative years and additional re-enforcement through continuing
medical education programs.
More efforts are needed to increase awareness of the need to institute
deprescribing GI medications for the common cold in the primary care
setting and improve the quality of prescription by determining whether a
prescription is necessary. In addition, continued research on
unnecessary GI medication utilisation, public health campaigns, and
regulatory policies from various healthcare stakeholders are needed.