Transcript RU overusing PPI’s?

“Should I add a PPI?”
A review of inpatient GI prophylaxis
Lenny Noronha, MD
Associate Professor, Hospitalist Section
2/5/10
Case 1
Mrs. Lowdee
- 78yf POD 2 s/p L hip ORIF
- Consult for opiate-rel delirium
- Changed to toradol 15mg IV q8h
- Nurse calls for am lab drop in H/H.
“I did that to her.”
‘Maybe I should have put her on a PPI…’
Case 2
Dr. Coldfeet
- 35ym a couple years out of residency
- Notices housestaff, colleagues use PPI’s left
and right for inpatient GI prophylaxis.
- Not sure whether to adopt practice
Doesn’t want partners to notice omission and
gossip about incompetence.
Thanks to
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Rush Pierce, MD
Jim Little, RN
David Hedberg
Kendall Rogers, MD
Sanjeev Arora, MD
Objectives
• Review current
appropriate use of GI
prophylaxis
• Discuss literature of risk
• Display UNM IM use,
concerns
Underlying Concepts
• Efficacy:Harm, Perceived Safety, Cost,
– Estrogen, Bb, Bisphosphonates, Statins (Taylor)
• Extrapolation (ICU -> SAC/ward)
• Dangers of templates, following patterns of
supervisors/peers
Volume 330:377-381 February 10, 1994
Number 6
Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients
Deborah J. Cook, Hugh D. Fuller, Gordon H. Guyatt, John C. Marshall, David Leasa, Richard Hall,
Timothy L
• 2252 patients > 16 yo adm to med/surg ICU’s
in 4 academic medical centers
• Risk of “clinically important” bleeding in
“critically ill”
Risk Factors for Clinically Important Bleeding among 2252 Patients Admitted to an Intensive Care
Unit
Conclusion: You don’t have to prophylax critically ill patients unless they
have coagulopathy or require mechanical ventilation.
Risk Factors for ICU UGIB*
• Mechanical ventilation > 48 hours
• Coagulopathy
– INR > 1.5
– Platelets < 50K
• UGIB within past year
• Chronic Liver, Kidney Disease
• +/- Steroids
* Multiple meta-analyses
Outside the ICU
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Quadeer MA, “Hospital-Acquired Gastrointestinal Bleeding Outside the Critical
Care Unit Risk Factors, Role of Acid Suppression, and Endoscopy Findings”,
Journal of Hospital Medicine, Jan/Feb 2006, Vol 1, Issue 1
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Retrospective review of 17,701 non-GI patients admitted to medicine ward
academic hospital who bled at least 24 hours after admission AND bouncebacks
for UGIB within 1 month.
• 0.4% clinically significant bleeding rate. No
benefit from PPI or other prophylaxis.
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Nonsignificant trend toward PPI benefit for patients on therapeutic
anticoagulation or clopidogrel
PPI, H2, Sucralfate, Maalox?
• Efficacy over placebo for all agents established
– Shuman RB, “Prophylactic therapy for stress ulcer bleeding: a reprisal.”
Ann Internal Med, Apr 1987; 106(4): 562-7.
– Cook DJ, “Stress ulcer prophylaxis in the critically ill: a meta analysis”
Am J Med, Nov 1991; 91(5):519-27
• Decreased incidence in clinically significant
UGIB and mortality with PPI over H2, other
agents.
– Conrad SA, et al, Critical Care Med, Apr 2005; 33(4); 760-5.
Risk of Harm Data
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Risk of Community-Acquired Pneumonia and Use of Gastric Acid–Suppressive Drugs, Robert J. F. Laheij; Miriam C.
J. M. Sturkenboom; Robert-Jan Hassing; Jeanne Dieleman; Bruno H. C. Stricker; Jan B. M. J. Jansen, JAMA, October
27, 2004; 292: 1955 - 1960.
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Acid-Suppressive Medication Use and the Risk for Hospital-Acquired Pneumonia Shoshana J. Herzig, MD;
Michael D. Howell, MD, MPH; Long H. Ngo, PhD; Edward R. Marcantonio, MD, SM
JAMA. 2009;301(20):2120-2128.
HAP: 63, 878 non-ICU admissions over 3 days in an
academic medical center. “pharmacoepidemiologic cohort
study”
Association of Proton Pump Inhibitor Therapy With Spontaneous Bacterial Peritonitis in Cirrhotic Patients With
Ascites Jasmohan S Bajaj MD, MS, Yelena Zadvornova MD, Douglas M Heuman MD,
Muhammad Hafeezullah MBBS, Raymond G Hoffmann PhD, Arun J Sanyal MD and Kia Saeian MD, MS, Am J
Gastroenterol 104: 1130-1134; March 31, 2009; doi:10.1038/ajg.2009.80
Rates of Hospital-Acquired Pneumonia According to Acid-Suppressive Medication Status
Herzig, S. J. et al. JAMA 2009;301:2120-2128.
Half of patients on acid-suppressing medicine (83% PPI)
30%
higher riskcomments:
of HAP with PPI.
Headline:
highest risk inUS
firstdeaths!
48hrs,
Authors’
33,000
preventable
seemed to decr with time.
NNH 111
180,000 HAP, 18% mortality
Copyright restrictions may apply.
Other suggested risks…
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C. diff
Enteric infections (salmonella, campylobacter)
Hip fracture
B12 deficiency
Decreased absorption of B12, iron and calcium
Gastric, colon polyps
Long-term Safety Concerns with Proton Pump Inhibitors, Ali T, Roberts DN, The American
Journal of Medicine, Oct 2009 (Vol. 122, Issue 10, 896-903)
Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture Yu-Xiao Yang, MD,
MSCE; James D. Lewis, MD, MSCE; Solomon Epstein, MD; David C. Metz, MD
JAMA. 2006;296:2947-2953.
Cost (per dose)
Drug
Cost to UNM
Patient Charge
Nexium PO
$6.19
$14.90
Protonix PO
$4.79
$12.12
Protonix IV
$28.20
$67.60
2009 Q3 UNMH PPI Use
1800
42%
1600
1400
1200
1000
Total DC's
800
PPI used
600
400
200
0
FP
IM
Gen Surg
Peds
ICU vs SAC/Wards 2009 PPI Use
36%
1600
1400
1200
1000
Total DC's
PPI use
800
600
400
200
0
ICU
SAC/Ward
- 72% of ICU pts on PPI
- Cardiology excluded
Appropriate GI Prophylaxis with PPI
• Ventilated, coagulapathic or therapeutically
anticoagulated critically ill patients
• Continue PPI on outpatient users
– Consider potential absorption effects (Ca, Fe, etc)
• What about Plavix patients?
Stay tuned for guidelines updates, quality
marker implementation
Plan of Attack
• This talk
• Change Inpatient Provider Progress Note
– Remove “Nutrition/GI prophylaxis” prompt
• Empower Clinical Pharmacists
• Report 2010 Q1 IM use at May business
meeting
Thank you