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Atlas Focus Report: Proton Pump Inhibitor medicines

This Australian Atlas of Healthcare Variation focus report examines rates of PBS prescription dispensed for proton pump inhibitor (PPI) medicines for people aged 75 years and over between 2018 and 2019. The findings from this report help identify areas for improvement for reducing inappropriate use of PPIs. 

Key findings

47% of people aged 75 years and over

had at least one PPI prescribed

Rates were higher

in inner regional areas than elsewhere

Rates increased

with socioeconomic disadvantage

Report Summary

  • In 2018–19, more than 7.1 million Pharmaceutical Benefits Scheme (PBS) prescriptions were dispensed for a PPI medicine for people aged 75 years and over. 
  • The rate was 5.9 times as high in the area with the highest rate as in the area with the lowest rate. 
  • Almost half (47%) of people aged 75 years and over had at least one PBS prescription dispensed for a PPI medicine; more than one-third (38%) had at least four prescriptions dispensed in the year, suggesting long-term PPI medicine use. 
  • There was substantial variation in rates of dispensing of high-dose PPI medicines between Primary Health Networks (PHNs). The rate was 6.1 times as high for the PHN with the highest rate as for the PHN with the lowest rate.

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PPI medicines are one of the most commonly used medicines in Australia, particularly among older people. PPI medicines are highly effective in managing gastro-oesophageal reflux disease (GORD), but are often used long term without reassessment of need. 

Older people may be particularly susceptible to harms from long-term use. These harms include unnecessary complexity in medicine regimens, unnecessary costs and possible rare but serious adverse effects.

Increased PBS restrictions for prescribing PPI medicines for GORD, introduced in May 2019, should help to reduce inappropriate long-term use, particularly of high-dose PPI medicines. 

Interventions that actively engage clinicians and encourage them to regularly review the need for PPI medicines in older people remain a priority. A greater focus is needed on educating people at every suitable opportunity about lifestyle measures that can be taken to reduce reflux. Improved consumer awareness of the appropriate timing of PPI medicine dosing may also improve the effectiveness of treatment and reduce the need for higher doses or long-term use.

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What are PPIs?

PPIs are a group of medicines that reduce stomach acid production.1 They reduce the potential for reflux of stomach acid into the oesophagus, and promote healing of inflammation and ulcers in both the oesophagus and the stomach. PPI medicines available in Australia include omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole.2,3 They are available by prescription; some are also available as over-the-counter medicines in lower strengths and pack sizes. 

PPI medicines are one of the most commonly dispensed medicines for older people.4 They are most often used to manage GORD.5 They are also used in people at high risk of gastrointestinal bleeding who need to take medicines such as non-steroidal anti-inflammatory drugs (NSAIDs), which can increase this risk.3,5,6 

GORD affects about 11% of Australian adults and rates of disease do not significantly change with age.7,8 People with GORD have frequent symptomatic reflux on two or more days of the week, or reflux that is severe enough to affect their quality of life.9 PPI medicines, accompanied by lifestyle modifications, are recommended as first-line treatment for GORD because they provide fast symptom relief and are more effective than less potent acid-suppression medicines.2,3,10,11

Guidelines for treating GORD recommend starting with a standard-strength PPI medicine for 4–8 weeks. A ‘step-up’ approach to a higher dose is recommended only if symptoms are severe.2,3,11 If symptoms are well controlled after initial treatment, treatment can be ‘stepped down’ to a lower dose or stopping altogether can be tried.2,3 More than two-thirds of people may be able to stop taking PPI medicines altogether, without their symptoms returning, after an initial course of treatment; gradual tapering of the dose is the most successful, particularly if the initial dose was high.12,13

Despite guideline recommendations, research suggests that many older people treated for GORD continue to take a PPI medicine long term without reassessment of need.14-16 The issue highlights the importance of discussion with people at the time of prescribing PPI medicines about the natural course of GORD, and the role of lifestyle changes in reducing reflux symptoms long term. Lifestyle measures, such as modifying diet, losing weight and stopping smoking, are an essential part of GORD treatment because they reduce reflux and reduce the risk of oesophageal cancer.3 

Guidelines also recommend PPI medicines for people at high-risk of GI bleeding who need ongoing treatment with NSAIDs, including low-dose aspirin for management of cardiovascular disease.3,6 Older age is a risk factor for GI bleeding from NSAID use3, and so PPI medicines are prescribed in older people for the duration of NSAID use to reduce this risk.3,6 Bleeding risk can also be reduced by taking other measures; for example, using the least potent NSAID for the shortest duration possible, or treating other risk factors such as Helicobacter pylori (H. pylori) infection, if present.17,18 

PPI medicines also have a role in treating mild to intermittent reflux. About 15–20% of adults experience reflux on an intermittent basis.9 Symptoms can often be managed with the lifestyle modifications described above. If acid suppression treatment is needed, guidelines recommend an antacid or, if needed, a more potent medicine, such as a histamine 2 receptor antagonist (H2 antagonist) or a PPI medicine.3,11,19 Over-the-counter PPI medicines are available for treating mild to intermittent reflux, however rates of their use are not readily available.

The Third Australian Atlas of Healthcare Variation mapped PBS dispensing of PPI medicines for people aged 18 years and over.20 More than 21 million PBS prescriptions for PPI medicines were dispensed in Australia in 2016–17. The dispensing rate was 5.0 times as high in the area with the highest rate as in the area with the lowest rate. Dispensing rates were also higher in areas with socioeconomic disadvantage in major cities, and in inner and outer regional areas. Overall, 15% of the adult population had a least one prescription for a PPI medicine dispensed during the year. 

Clinical commentary

Concerns about high rates of PPI medicine dispensing and potentially inappropriate long-term use have been expressed for years.21 Recent Australian research has shown that older people are substantially higher users of PPI medicines than younger adults.14 This pattern is also seen in many comparable countries, such as New Zealand, the United Kingdom, the United States and Canada.22-28 Concerns have also been raised about the long-term use of PPI medicines in older people without a clear indication.14,29,30

In a population study, rates of PPI medicine use per 100 people in Australia were 42.2 for people aged 75–84 years and 42.8 for people aged 85 years and over, compared with 12.5 for the whole population, between 2013 and 2016.14 Of people aged 75 years and over who started treatment with a PPI medicine, 42% continued to take it for longer than 12 weeks, and 31% took it for more than 12 months, either intermittently or continuously. The study also found that a substantial proportion of people who continued to take a PPI medicine after 12 weeks did so at the dose they were started on. PPI medicines were more commonly prescribed in people who were taking more medicines than in those who were taking fewer. 

An Australian study of 41,000 veterans (average age of 79 years) prescribed PPI medicines for GORD found that more than two-thirds did not have their therapy reduced or stopped after eight weeks of treatment, as recommended in guidelines. Thirty-eight percent continued PPI medicines for one year.15 

Similar trends have been observed in Australian aged care homes. Half to three-quarters of residents have been found to take PPI medicines for durations longer than recommended.16,31,32 Rates of PPI medicine use are also higher among residents who take more medicines than among those taking fewer.33

Although PPI medicines have a good safety profile, there are concerns about potential harms associated with long-term use in older people, prompting an increased focus on regularly reviewing the need for these medicines.6 Long-term use has been linked to an increased risk of hip fracture.34 PPI medicines alter the gut microbiome, and there is some evidence that this may increase the risk of type 2 diabetes, as well as infections with Clostridium difficile and other pathogens.35,36 PPI medicines can also increase the risk of vitamin B12 deficiency and kidney complications.6,10,37,38 Older people may be more susceptible to these harms than younger people because of increased frailty and age-related physiological changes that alter the way that their bodies respond to medicines.31,39 Many older people also have multiple conditions requiring treatment with multiple medicines, which also increases their risk of medicine-related harm.31 Although the absolute risk of these adverse effects is low, the population impact may be high because of the number of older people taking PPI medicines.16

PBS changes 

On 1 May 2019, restrictions on PPI medicines came into effect that aim to improve the appropriateness of their use. These changes aim to reduce unwarranted long-term use, particularly high-dose use among older people.40,41 Key changes include the reclassification of doses, increased restrictions on high-dose and standard-dose PPI medicines for GORD, changes to the number of repeat prescriptions and the addition of new item numbers for standard doses.

Data are sourced from the PBS dataset, which includes all prescriptions dispensed under the PBS and the Repatriation Pharmaceutical Benefits Scheme (RPBS), including under co-payment prescriptions. 

Data used in this report exclude doctors’ bag items and any programs with alternative supply arrangements (section 100 of the National Health Act 1953) where patient level details are not available, such as direct supply to remote Aboriginal health services. 

The PBS and RPBS do not cover medicines supplied to public hospital inpatients, over-the-counter medicines or private prescriptions. The dataset does not allow analysis by Aboriginal and Torres Strait Islander status. 

Rates are based on the number of prescriptions dispensed for PPI medicines per 100,000 people aged 75 years and over in 2018–19, unless otherwise indicated. For defined daily dose (DDD), the rate is calculated per 1,000 people per day. Patient counts reflect the number or unique patients, regardless of the number of prescriptions the patient may have received in the year. 

The data do not include PPI medicines in fixed-dose combinations with antibiotics. The analysis and maps are based on the patient’s postcode recorded in their Medicare file and not the location of the prescriber or the dispensing pharmacy. 

Rates are age and sex standardised to allow comparisons between populations with different age and sex structures.

Some data have been suppressed to manage volatility and confidentiality. This process takes into account the Australian Government Department of Health’s requirements for reporting PBS data. Data suppression for this item has been particularly marked for remote areas of the Northern Territory.

In 2018–19, there were 7,114,281 PBS prescriptions dispensed for PPI medicines to people aged 75 years and over, representing 418,360 prescriptions per 100,000 people aged 75 years and over (the Australian rate). 

The number of prescriptions dispensed for PPI medicines across 328* local areas (Statistical Area Level 3 – SA3) ranged from 131,393 to 777,098 per 100,000 people aged 75 years and over. The rate was 5.9 times as high in the area with the highest rate compared with the area with the lowest rate. The number of prescriptions dispensed for PPI medicines varied across states and territories, from 257,216 per 100,000 people aged 75 years and over in the Northern Territory to 462,138 in Tasmania. 

After the highest and lowest 10% of results were excluded, 264 SA3s remained. The number of prescriptions per 100,000 people aged 75 years and over was 1.4 times as high in the SA3 with the highest rate compared with the SA3 with the lowest rate. 

Analysis by remoteness and socioeconomic status 

Rates for PBS prescriptions for PPI medicines for people aged 75 years and over were higher in inner regional areas than elsewhere. Rates increased with socioeconomic disadvantage.

Analysis by people dispensed at least one prescription for a PPI medicine by state and territory 

In 2018–19, the number of people aged 75 years and over dispensed at least one PPI medicine prescription was 794,861, representing 47% of people aged 75 years and over in Australia. 

Analysis by people dispensed at least four prescriptions for a PPI medicine by state and territory 

In 2018–19, the number of people aged 75 years and over dispensed at least four prescriptions for a PPI medicine was 639,243, representing an average of 38% of people aged 75 years and over in Australia. 

Analysis by dose (high, standard and low*) and PHN 

The number of prescriptions dispensed for high-dose PPI medicines varied across PHNs, from 15,746 per 100,000 people aged 75 years and over in the Northern Territory to 96,557 in Tasmania. The rate was 6.1 times as high for the PHN with the highest rate as for the PHN with the lowest rate. 

The number of prescriptions dispensed for standard dose PPI medicines varied across PHNs, from 205,806 per 100,000 people aged 75 years and over in the Northern Territory to 403,499 in Murrumbidgee. The rate was 2.0 times as high for the PHN with the highest rate as for the PHN with the lowest rate.

The number of prescriptions dispensed for low-dose PPI medicines varied across PHNs, from 22,303 per 100,000 people aged 75 years and over in South Western Sydney to 55,928 in Western Queensland. The rate was 2.5 times as high for the PHN with the highest rate as for the PHN with the lowest rate. 

Variations in rates of PPI medicine dispensing in people aged 75 years and over are likely to be due to the geographical differences in the factors discussed below. 

Variation between areas may not directly reflect the practices of the clinicians who are based in these areas. The analysis is based on where people live rather than where they obtain their health care. Patients may travel outside their local area to receive health care.

Rates of underlying disease 

Variation is warranted and desirable when it reflects variation in the underlying need for care. The higher PPI medicine dispensing rates seen in socioeconomically disadvantaged areas in the report may reflect the prevalence of GORD and its risk factors (such as obesity, smoking, poor diet and alcohol intake), which are more common among people with lower levels of education and higher socioeconomic disadvantage.4,42 

The prevalence of arthritis and rates of NSAID use to manage symptoms may also contribute to variation in PPI medicine dispensing.3 PPI medicines are used to reduce the risk of gastrointestinal bleeding for people who need ongoing treatment with an NSAID and are at high risk of gastrointestinal bleeding. Almost half (49%) of people aged 65 years and over have arthritis, according to self-reported data.43

Use of low-dose aspirin may also contribute to variation in PPI medicine use. PPI medicines are also often prescribed to prevent gastrointestinal bleeding associated with medicines other than NSAIDs and low-dose aspirin, although this practice is not well supported by evidence.14

The prevalence of untreated H. pylori infection and rates of peptic ulcer disease may affect rates of PPI medicine dispensing. Infection rates, which increase the risk of peptic ulcer disease, are higher in older people. Rates of people with untreated H. pylori infection starting on an NSAID may also affect PPI dispensing. For people taking an NSAID, H. pylori infection increases the risk of peptic ulcer disease by up to 3.5 times, compared with no infection.17

Clinical decision-making 

Variation in adherence to guidelines is likely to influence patterns of use, particularly adherence to recommendations to assess ongoing need for a PPI medicine. 

Clinician and consumer willingness to discuss the natural history of reflux, the risks and benefits of treatment, and approaches to addressing lifestyle factors such as obesity and diet may influence PPI medicine use. Some people with uncomplicated GORD may be using PPI medicines long-term without attempting to step down to a lower dose or a less potent medicine, or to cease altogether. This may be due to concerns about symptoms re-emerging, or because the clinician and consumer have not discussed other treatment strategies, so that they may not be aware that it is possible to stop taking PPI medicines. 

Taking PPI medicines at an inappropriate time of day may lead to variation in effectiveness of the medicines and how well reflux symptoms are controlled. Some people may not be aware that PPI medicines are most effective after a prolonged fast and should be taken at least half an hour before the first meal of the day.2,3 Poor packing of PPI medicines in dose administration aids may contribute to this problem.

Variation may also reflect lack of transfer of information when people are discharged from hospital or move between other healthcare settings. Important information includes what a PPI medicine was prescribed for and when it should be reviewed or stopped. Medicines that are continued without clear instructions about when they should be reviewed or stopped can have downstream effects on ongoing prescribing and contribute to unnecessary medicine use.44

Access to medical care 

Access to general practitioners and gastroenterologists may influence the likelihood of consumers seeking care for GORD, and therefore affect rates of PPI medicine use. Variation in rates of PPI medicine dispensing between areas may also be influenced by the number of clinicians providing services to people living in the area. The practice styles of individual clinicians may be more likely to affect rates in areas with fewer clinicians, such as rural and regional locations, than in areas with more clinicians. 

Uptake of PBS changes 

Regulatory changes to the PBS listings for PPI medicines made in May 2019 – at the end of the data collection period for this report – might be expected to have more impact on rates in areas in which adherence to guidelines has been low. However, the effect on findings is probably small because the changes applied only to new PBS prescriptions dispensed from this date. 

Over-the-counter use of PPI medicines 

Australians are high consumers of over-the-counter medicines.43 Ability to afford over-the-counter medicines may have contributed to the lower rates of PPI medicine dispensing in areas of socioeconomic advantage. However, most people aged 75 years and over have a concession or pension card, so the effect of this may be small.

Regulatory changes 

Changes to the PBS restrictions, dose classifications and number of repeat prescriptions for PPI medicines came into effect in Australia in May 2019.40 These changes followed advice from the Drug Utilisation Sub Committee of the Pharmaceutical Benefits Advisory Committee that, given guideline recommendations and the prevalence of GORD in Australia, high-dose PPI medicines appear to be overprescribed for long periods, particularly in older people.40,41 The changes aim to encourage clinical review of PPI medicines and reduce inappropriate long-term use, particularly of high-dose PPI medicines. The effect of these regulatory changes is yet to be evaluated. 

Reviewing the need for PPI use 

Australia’s National Indicators for Quality Use of Medicines in Australian Hospitals 2014 can be used to monitor safe and appropriate medicines use.45 An indicator to measure long-term PPI medicine use may be helpful in identifying people who would benefit from ceasing therapy (deprescribing). Employing pharmacists in general practice clinics as part of a team-based model of care may increase access to medicine review and education services. These models are well established internationally, and further research on their effectiveness in the Australian healthcare system is needed.46

Consumer and clinician education 

Multifaceted national education campaigns that focus on reviewing the need for PPI medicines and actively stepping down or deprescribing when the medicine is no longer needed appear to have the most success in improving PPI medicine use, particularly in the veteran population.47-49

Lifestyle factors 

Educating people about addressing lifestyle factors that may trigger symptoms is an important part of GORD treatment. Having a poor diet – particularly a diet high in fat – as well as smoking and being overweight, can exacerbate symptoms and increase the risk of oesophageal cancer. Weight loss has particularly been shown to reduce the symptoms of GORD.52,53 In women, a 3.5 kg/m2 reduction in body mass index can result in nearly a 40% reduction in the risk of having frequent GORD symptoms.54 Addressing these risk factors for GORD has the added benefit of improving health in general.3,9,10 

Optimising effectiveness of PPI medicines 

Educational and other initiatives that target the importance of taking PPI medicines on an empty stomach may improve medicine effectiveness and reduce dose increases. Strategies that improve clinician uptake of guideline recommendations for H. pylori testing and treatment may help reduce variation in PPI medicine use. Routine H. pylori testing and, if needed, treatment, before prescription of NSAIDs may also reduce the risk of peptic ulcer.17

About the data

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Atlas Focus Report: Opioid medicines dispensing

Atlas Focus Report: Opioid medicines dispensing
Atlas Focus Report: Medication Management Reviews

Atlas Focus Report: Medication Management Reviews
Atlas Focus Report: Polypharmacy

Atlas Focus Report: Polypharmacy

Last updated: 13 October 2026