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.