Proton pump inhibitors (PPIs) are one the most commonly prescribed medications globally. They are the mainstay of management of acid-related gastrointestinal disorders¹. Since their introduction in the late 1980s, PPIs named omeprazole, pantoprazole, lansoprazole, rabeprazole, and esomeprazole have replaced H₂ receptor antagonists due to superior acid suppression and mucosal healing rates².

PPIs act by irreversibly inhibiting the H⁺/K⁺ ATPase enzyme system in gastric parietal cells, suppressing basal and stimulated gastric acid secretion³. They are indicated for gastroesophageal reflux disease (GERD), peptic ulcer disease, Helicobacter pylori eradication regimens, Zollinger–Ellison syndrome, and stress ulcer prophylaxis in high-risk hospitalized patients⁴.

In spite of guideline-based indications, previous studies have showed significant overuse and inappropriate continuation of PPIs in inpatient and outpatient settings⁵. Heidelbaugh et al. reported that up to 70% of PPI prescriptions lacked appropriate indications⁶. Forgacs and Loganayagam also reported concerns regarding long-term prescribing without reassessment⁷.

Long-term PPI use has been associated with side effects like Clostridioides difficile infection⁸, community-acquired pneumonia⁹, vitamin B12 deficiency¹⁰, hypomagnesemia¹¹, chronic kidney disease¹², osteoporosis-related fractures¹³, and possible cardiovascular risks¹⁴. Though causality is debated in certain associations, professional bodies -American Gastroenterological Association (AGA) have issued deprescribing guidelines for periodic review¹⁵.

In India, studies evaluating prescribing patterns have reported common empirical use, especially for dyspepsia and stress ulcer prophylaxis¹⁶. A cross-sectional study among resident doctors in Pune found moderate knowledge but inappropriate prescribing practices¹⁷. Same pattern of inappropriate PPI utilization and lack of periodic reassessment have been reported in other tertiary care settings in India¹⁸.

Understanding clinicians’ knowledge, attitude, and behavior (KAB) is important in designing targeted interventions for rational drug use. Data from Andhra Pradesh is limited. So, this study aimed to assess the knowledge, attitude, and behavior of clinicians toward PPI use in a tertiary care hospital in Nandyal.

AIM

To evaluate the knowledge, attitude, and behavior of clinicians toward the use of proton pump inhibitors (PPIs) in a tertiary care hospital in Nandyal, Andhra Pradesh.

OBJECTIVES

1. To assess the level of knowledge regarding the indications, dosing, duration, mechanism of action, and adverse effects of proton pump inhibitors among clinicians.
2. To evaluate the attitudinal perspectives of clinicians toward the appropriate use, safety, and long-term prescribing of proton pump inhibitors.
3. To assess the behavioral practices of clinicians related to prescribing patterns, continuation, and rational use of proton pump inhibitors.

MATERIAL AND METHODS

Study Design: Hospital-based cross-sectional study.

Study Area: Tertiary care hospital, Nandyal.

Study Period: 90 days.

Study Population: Clinicians (consultants, residents, medical officers).

Sample Size: 200 (convenience sampling).

Sample Size Calculation

The sample size was calculated using the single population proportion formula, as the study aimed to estimate the proportion of clinicians with adequate knowledge and rational practices regarding proton pump inhibitor (PPI) use.

The formula used was:

n=Z2/p×qd2

Since previous similar studies in India reported approximately 50% prevalence of adequate knowledge regarding PPI use, the prevalence (p) was assumed to be 50% (0.5) to obtain the maximum sample size.

Thus:

p = 0.5

q = 1 − 0.5 = 0.5

Z = 1.96, d = 7% (0.07)

The calculated minimum sample size was 196. After rounding off and accounting for possible non-response, the final sample size was taken as 200 clinicians or postgraduates.

Study Tool: Pre-designed, pre-tested semi-structured questionnaire developed based on previously published data and guideline recommendations¹⁵,¹⁷.

The questionnaire included four sections:

Section I: Socio-demographic details

Section II: Knowledge (20 yes/no questions; max score 20)

Section III: Attitude (8 yes/no items; max score 8)

Section IV: Behavior (7 items scored as Always=0, Often=1, Never=2)

The questionnaire consisted of four sections.

1. The first section included socio-demographic questions.
2. The second, third, and fourth sections assessed knowledge (20 questions), attitude (8 items), and behavior (7 items) with respect to PPI usage.
3. The options for all twenty knowledge questions were set as “Yes” or “No.” A correct response was awarded one point, and an incorrect response was given zero points. The maximum attainable score in the knowledge section was twenty.
4. In the attitude section, the eight questions had response options of “Yes” or “No.” Participants who responded affirmatively were awarded one point, whereas negative responses were given zero points.
5. The behavior section consisted of seven questions, with response options categorized as “Always” (0 points), “Often” (1 point), and “Never” (2 points).

RESULTS

200 clinicians participated in the study. The findings are presented under four sections: socio-demographic characteristics, knowledge, attitude, and behavior.

Demography: Most participants were female. Commonly seen age group was 24-33 years. Most common qualification was MBBS with MD/MS(including pursuing candicates). Junior residents constitute most participants.

Table 1: Socio-Demographic Characteristics of Participants (n = 200)

Knowledge:

Most clinicians showed good knowledge regarding basic pharmacology and indications of PPIs. 98% correctly identified commonly used PPIs and 97% understanding their mechanism of action. But, misconceptions were seen in certain areas, like using PPIs in acute pancreatitis and the concept that all PPIs are prodrugs. Overall, the mean knowledge score indicated a moderate level of awareness among clinicians.

Table 2: Knowledge Regarding Proton Pump Inhibitor Use (n = 200)

Attitude Toward PPI Use

Most clinicians showed positive attitude toward rational PPI use, with 96% acknowledging that overuse is common in clinical practice. Nearly all participants agreed on the necessity for regular review of long-term therapy and large-scale educational initiatives.

Graph 1: Attitude Toward PPI Use (n = 200)

Mean Attitude Score: 5.6 ± 1.4 (Maximum = 8)

Behavioral practices showed routine prescribing of PPIs for conditions such as abdominal pain, dyspepsia, and NSAID co-therapy. Many clinicians reported prescribing PPIs routinely, although reassessment before continuation was not consistently practiced. These findings indicate a gap between knowledge and actual prescribing behavior.

Graph 2: Prescribing Behavior of Clinicians (n = 200)

Mean Behavior Score: 8.1 ± 2.0 (Maximum = 14)

DISCUSSION

This study evaluated clinicians’ knowledge, attitude, and behavior regarding PPI use in a tertiary care hospital in Nandyal. The findings showed moderate-to-good knowledge levels.  The high awareness regarding mechanism (97%) and drug examples (98%) aligns with findings from Strand et al., who reported strong foundational knowledge among practicing physicians².  But, misconceptions about indications like acute pancreatitis mirror findings from the Pune study by Suryawanshi et al., in which 52% of residents incorrectly considered PPIs beneficial in pancreatitis¹⁷. The acknowledgment of overuse by 96% of respondents is consistent with Heidelbaugh et al., who documented inappropriate PPI use in 68% of hospitalized patients⁶.  Scarpignato et al. Informed that prophylactic use without risk stratification is a global issue^5.

Regarding safety awareness, 91% recognized long-term adverse effects. Lazarus et al. showed an association between PPI use and chronic kidney disease¹². Yu et al. linked long-term use to fracture risk¹³. Awareness of these risks may explain the strong support for educational initiatives observed in our study. The predominant use of pantoprazole (40%) informs similar prescribing trends reported in Indian tertiary hospitals¹⁶. Pantoprazole’s relatively favorable interaction profile compared to omeprazole may influence clinician preference³.

In spite of adequate knowledge, behavioral findings indicate routine empirical prescribing for abdominal pain and dyspepsia. Forgacs and Loganayagam previously showed that PPIs are commonly used as a “quick fix” for nonspecific symptoms⁷. This suggests that system-level interventions, than knowledge alone, are required. International deprescribing guidelines recommend periodic review of indication and dose reduction where appropriate¹⁵. The near-universal agreement in our study supporting review of ongoing therapy suggests readiness for implementation of stewardship programs.

Strengths include adequate sample size and comprehensive KAB assessment. Limitations include single-center design, convenience sampling, and reliance on self-reported behavior. Future multicenter studies and prescription audits are recommended to objectively measure inappropriate use and assess intervention impact.

Proton pump inhibitors represent a classic example where highly effective drugs are frequently prescribed beyond evidence-based indications or for prolonged durations without periodic review. The high proportion of clinicians in our study acknowledging overuse (96%) shows awareness of the problem. But, bridging the gap between knowledge and rational prescribing behavior requires structured interventions like clinical audits, guideline dissemination, pharmacovigilance reinforcement, and continuous medical education programs. In a study done previous in Andhra Pradhes, knowledge and awareness of pharmacovigilance increased significantly with the year of study. First-year students showed poor awareness in most areas. Second-, third-, and fourth-year students showed progressively better knowledge regarding the definition, processes, surveillance phases of pharmacovigilance, and identification of ADRs. ¹⁹.

CONCLUSION

Clinicians showed reasonable knowledge and positive attitudes toward safe PPI use. But, prescribing behaviors indicatoveruse and empirical prescribing patterns. Structured educational programs, institutional guidelines, and stewardship strategies are recommended to promote rational PPI use.

REFERENCES

1. Strand DS, Kim D, Peura DA. 25 years of proton pump inhibitors: A comprehensive review. Gut Liver. 2017;11(1):27–37.
2. Sachs G, Shin JM, Howden CW. The clinical pharmacology of proton pump inhibitors. Aliment Pharmacol Ther. 2006;23 Suppl 2:2–8.
3. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):27–56.
4. Freedberg DE, Kim LS, Yang YX. The risks and benefits of long-term use of proton pump inhibitors: expert review and best practice advice from the AGA. Gastroenterology. 2017;152(4):706–15.
5. Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases: a position paper. BMC Med. 2016;14:179.
6. Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton pump inhibitors: a review. Am J Gastroenterol. 2012;107(1):81–7.
7. Forgacs I, Loganayagam A. Overprescribing proton pump inhibitors. BMJ. 2008;336(7634):2–3.
8. Janarthanan S, Ditah I, Adler DG, Ehrlich AC. Clostridium difficile–associated diarrhea and PPI therapy: a meta-analysis. Am J Gastroenterol. 2012;107(7):1001–10.
9. Lambert AA, Lam JO, Paik JJ, Udaltsova N, Yao J, Monto AS, et al. Risk of community-acquired pneumonia with PPI therapy. Clin Infect Dis. 2015;60(2):111–8.
10. den Elzen WPJ, Groeneveld Y, de Ruijter W, et al. Long-term PPI use and vitamin B12 deficiency. J Am Geriatr Soc. 2008;56(4):660–4.
11. Hess MW, Hoenderop JGJ, Bindels RJM, Drenth JPH. Hypomagnesaemia induced by proton pump inhibition. Aliment Pharmacol Ther. 2012;36(5):405–13.
12. Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238–46.
13. Yu EW, Blackwell T, Ensrud KE, et al. Acid-suppressive medications and fracture risk. Arch Intern Med. 2011;171(11):993–1001.
14. Shah NH, LePendu P, Bauer-Mehren A, et al. Proton pump inhibitors and myocardial infarction risk. PLoS One. 2015;10(6):e0124653.
15. Targownik LE, Fisher DA, Saini SD. AGA clinical practice update on deprescribing of proton pump inhibitors. Gastroenterology. 2022;162(4):1334–42.
16. Malhotra S, Pandhi P, Garg SK. Drug utilization study of proton pump inhibitors in a tertiary care hospital in India. Indian J Pharmacol. 2001;33(4):247–51.
17. Suryawanshi SP, Deshmukh VS, Patil SR. Knowledge, attitude and practices of resident doctors toward PPI use in Pune: a cross-sectional survey. Biomed Pharmacol J. 2023;16(3):1473–80.
18. Nalliah RP, et al. Evaluation of prescribing patterns and appropriateness of proton pump inhibitor use in a tertiary care hospital. J Clin Diagn Res. 2017;11(7):FC05–FC09.
19. Rajesh D, Venkatesh RS, Rachamanti R, Yashwanth M, Papolu C. A Study On Level Of Awareness On Pharmacovigilance Among Nursing Students Of Government Nursing College, Vijayawada-A Cross-Sectional Study.J Appl Bioanal. 2025;