Use of Proton Pump Inhibitors After Antireflux Surgery
Use of Proton Pump Inhibitors After Antireflux Surgery
In the period 1996–2010, 3642 patients underwent ARS, of which 177 (5%) were excluded because of rare procedure techniques (72) or because of age <18 at first-time surgery (105). The study population included 3465 patients (43% female, interquartile age range 18–60), of which 308 (8.9%) were censored before the end of follow-up because of death or emigration and 267 (7.8%) were censored because of re-ARS. A total of 1166 (33.7%) of eligible index ARS were performed in 1996–2000, 1324 (38.2%) in 2001–2005 and 975 (28.1%) in 2006–2010. Use of PPI in the year before index surgery was 0 DDD in 441 patients (12.7%), 1–89 DDD in 493 (14.2%), 90–179 DDD in 464 (13.3%) and ≥180 DDD in 2067 (59.7%).
An index prescription of PPI was redeemed by 2299 (66.4%, 95% CI 64.8 to 67.9). The 5-, 10- and 15-year cumulative risks for redeeming an index PPI prescription were 57.5% (95% CI 55.8 to 59.2), 72.4% (95% CI 70.7 to 74.2) and 82.6% (95% CI 79.9 to 85.1), respectively. Five-year risks of redeeming index PPI prescription were 49.7% (95% CI 46.8 to 52.6) for those operated in the period 1996–2000, 57.4% (95% CI 54.7 to 60.1) for those operated in the period 2001–2005 and 69.1% (95% CI 65.4 to 72.8) for those operated in the period 2006–2010. Kaplan–Meier curves for index PPI prescription, stratified after period of index ARS, are shown in figure 1.
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Figure 1.
Cumulative risk for redeeming proton pump inhibitor (PPI) prescriptions after antireflux surgery (ARS). Kaplan–Meier curves for patients undergoing ARS in 1996–2010 stratified after period of surgery. X-axis: time in years. Y-axis: cumulative risk of redeeming index prescription of PPI.
Long-term use of PPI was taken up by 1335 (38.5%, 95% CI 36.9 to 40.2). The 5-, 10- and 15-year risks of taking up long-term PPI use were 29.4% (95% CI 27.8 to 31.0), 41.1% (95% CI 39.2 to 43.0) and 56.6% (95% CI 53.5 to 59.7), respectively. The 5-year risks of taking up long-term use of PPI were 21.5% (95% CI 19.2 to 24.0) for those operated in the period 1996–2000, 28.6% (95% CI 26.2 to 31.2) for those operated in the period 2001–2005 and 43.3% (95% CI 39.6 to 47.4) for those operated in the period 2006–2010. Kaplan–Meier curves for long-term use of PPI, stratified after period of index ARS, are shown in figure 2.
(Enlarge Image)
Figure 2.
Cumulative risk for long-term proton pump inhibitor (PPI) use after antireflux surgery (ARS). Kaplan–Meier curves for patients undergoing ARS in 1996–2010 stratified after period of surgery. X-axis: time in years. Y-axis: cumulative risk of long-term use of PPI (defined as ≥180 defined daily dose/year).
The risks of redeeming an index PPI prescription and of long-term use of PPI were significantly affected by gender, age at operation, year of index ARS, previous use of PPI and use of NSAID or antiplatelet drugs (Table 1).
In the first sensitivity analysis on how outcome was affected by PPI therapy attributed to ulcer prophylaxis, patients were censored when they redeemed a prescription of NSAID or antiplatelet drugs. This resulted in a slight drop in the 5-year risk of redeeming index PPI prescription to 57.5% (95% CI 55.8 to 59.2) and a 5-year risk of taking up long-term PPI use of 27.3% (95% CI 25.3 to 29.5). The second sensitivity analysis showed that if we excluded PPI prescriptions associated with NSAID or antiplatelet prescriptions, the 5-year risk of redeeming index PPI prescription was 51.7% (95% CI 25.3 to 29.5). Kaplan–Meier curves for index PPI prescription and long-term use of PPI according to sensitivity analyses are shown in figures 3 and 4.
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Figure 3.
Cumulative risk for redeeming proton pump inhibitor (PPI) prescriptions, censored for presumed use as ulcer prophylaxis. Kaplan–Meier curves for patients undergoing antireflux surgery in 1996–2010. Data presented without sensitivity analyses (reference), censored at redemption of nonsteroidal anti-inflammatory drugs (NSAID) or antiplatelet prescription (1, sensitivity) and after exclusion of PPI prescriptions associated with NSAID or antiplatelet prescription (2, sensitivity). X-axis: time in years. Y-axis: cumulative risk of redeeming index prescription of PPI.
(Enlarge Image)
Figure 4.
Cumulative risk for long-term proton pump inhibitor (PPI) use after antireflux surgery (ARS), censored for presumed use as ulcer prophylaxis. Kaplan–Meier curves for patients undergoing ARS in 1996–2010. Data presented without sensitivity analyses (reference) and after censoring at redemption of nonsteroidal anti-inflammatory drugs or antiplatelet prescription (1, sensitivity). X-axis: time in years. Y-axis: cumulative risk of long-term use of PPI (defined as ≥180 defined daily dose/year).
Results
In the period 1996–2010, 3642 patients underwent ARS, of which 177 (5%) were excluded because of rare procedure techniques (72) or because of age <18 at first-time surgery (105). The study population included 3465 patients (43% female, interquartile age range 18–60), of which 308 (8.9%) were censored before the end of follow-up because of death or emigration and 267 (7.8%) were censored because of re-ARS. A total of 1166 (33.7%) of eligible index ARS were performed in 1996–2000, 1324 (38.2%) in 2001–2005 and 975 (28.1%) in 2006–2010. Use of PPI in the year before index surgery was 0 DDD in 441 patients (12.7%), 1–89 DDD in 493 (14.2%), 90–179 DDD in 464 (13.3%) and ≥180 DDD in 2067 (59.7%).
An index prescription of PPI was redeemed by 2299 (66.4%, 95% CI 64.8 to 67.9). The 5-, 10- and 15-year cumulative risks for redeeming an index PPI prescription were 57.5% (95% CI 55.8 to 59.2), 72.4% (95% CI 70.7 to 74.2) and 82.6% (95% CI 79.9 to 85.1), respectively. Five-year risks of redeeming index PPI prescription were 49.7% (95% CI 46.8 to 52.6) for those operated in the period 1996–2000, 57.4% (95% CI 54.7 to 60.1) for those operated in the period 2001–2005 and 69.1% (95% CI 65.4 to 72.8) for those operated in the period 2006–2010. Kaplan–Meier curves for index PPI prescription, stratified after period of index ARS, are shown in figure 1.
(Enlarge Image)
Figure 1.
Cumulative risk for redeeming proton pump inhibitor (PPI) prescriptions after antireflux surgery (ARS). Kaplan–Meier curves for patients undergoing ARS in 1996–2010 stratified after period of surgery. X-axis: time in years. Y-axis: cumulative risk of redeeming index prescription of PPI.
Long-term use of PPI was taken up by 1335 (38.5%, 95% CI 36.9 to 40.2). The 5-, 10- and 15-year risks of taking up long-term PPI use were 29.4% (95% CI 27.8 to 31.0), 41.1% (95% CI 39.2 to 43.0) and 56.6% (95% CI 53.5 to 59.7), respectively. The 5-year risks of taking up long-term use of PPI were 21.5% (95% CI 19.2 to 24.0) for those operated in the period 1996–2000, 28.6% (95% CI 26.2 to 31.2) for those operated in the period 2001–2005 and 43.3% (95% CI 39.6 to 47.4) for those operated in the period 2006–2010. Kaplan–Meier curves for long-term use of PPI, stratified after period of index ARS, are shown in figure 2.
(Enlarge Image)
Figure 2.
Cumulative risk for long-term proton pump inhibitor (PPI) use after antireflux surgery (ARS). Kaplan–Meier curves for patients undergoing ARS in 1996–2010 stratified after period of surgery. X-axis: time in years. Y-axis: cumulative risk of long-term use of PPI (defined as ≥180 defined daily dose/year).
The risks of redeeming an index PPI prescription and of long-term use of PPI were significantly affected by gender, age at operation, year of index ARS, previous use of PPI and use of NSAID or antiplatelet drugs (Table 1).
In the first sensitivity analysis on how outcome was affected by PPI therapy attributed to ulcer prophylaxis, patients were censored when they redeemed a prescription of NSAID or antiplatelet drugs. This resulted in a slight drop in the 5-year risk of redeeming index PPI prescription to 57.5% (95% CI 55.8 to 59.2) and a 5-year risk of taking up long-term PPI use of 27.3% (95% CI 25.3 to 29.5). The second sensitivity analysis showed that if we excluded PPI prescriptions associated with NSAID or antiplatelet prescriptions, the 5-year risk of redeeming index PPI prescription was 51.7% (95% CI 25.3 to 29.5). Kaplan–Meier curves for index PPI prescription and long-term use of PPI according to sensitivity analyses are shown in figures 3 and 4.
(Enlarge Image)
Figure 3.
Cumulative risk for redeeming proton pump inhibitor (PPI) prescriptions, censored for presumed use as ulcer prophylaxis. Kaplan–Meier curves for patients undergoing antireflux surgery in 1996–2010. Data presented without sensitivity analyses (reference), censored at redemption of nonsteroidal anti-inflammatory drugs (NSAID) or antiplatelet prescription (1, sensitivity) and after exclusion of PPI prescriptions associated with NSAID or antiplatelet prescription (2, sensitivity). X-axis: time in years. Y-axis: cumulative risk of redeeming index prescription of PPI.
(Enlarge Image)
Figure 4.
Cumulative risk for long-term proton pump inhibitor (PPI) use after antireflux surgery (ARS), censored for presumed use as ulcer prophylaxis. Kaplan–Meier curves for patients undergoing ARS in 1996–2010. Data presented without sensitivity analyses (reference) and after censoring at redemption of nonsteroidal anti-inflammatory drugs or antiplatelet prescription (1, sensitivity). X-axis: time in years. Y-axis: cumulative risk of long-term use of PPI (defined as ≥180 defined daily dose/year).
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