Intravenous proton pump inhibitor use in hospital practice

BEHIND THE PROTON PUMP INHIBITOR PRESCRIPTION: AN INTERNATIONAL SURVEY ON PHYSICIAN PRACTICES AND KNOWLEDGE

BACKGROUND

Proton pump inhibitors (PPIs) are widely prescribed worldwide, often resulting in their overuse. Consequently, it is essential to identify the likely causes of this overuse to facilitate their appropriate prescription.

OBJECTIVE

This study aims to assess physician prescribing patterns, their knowledge of PPIs, and factors affecting their knowledge.

METHODS

An online survey was conducted among Latin American and Spanish physicians, collecting the following data: professional information, patterns of PPI usage, familiarity with published evidence, and the management approach in three hypothetical case-scenarios. Participant knowledge was categorized as sufficient or insufficient based on the results of the case scenarios. Subsequently, subgroup analysis was performed based on physician training level, years in practice, specialty, and time since the last PPI literature review.

RESULTS

A total of 371 physicians participated in the survey. Thirty-eight percent frequently prescribe PPIs, primarily for prophylactic purposes (57.9%). Eighty percent were unfamiliar with PPI deprescribing strategies, and 54.4% rarely reviewed the ongoing indication of patients taking a PPI. Sixty-four percent demonstrated sufficient knowledge in the case-scenarios. A significant association was observed between specialty type (medical vs surgical: 69.4% vs 46.8%, P<0.001), the timing of the PPI indication literature review (<5 years vs >5 years: 71.4% vs 58.7%, P=0.010), and sufficient knowledge.

CONCLUSION

While most participants prescribed PPIs regularly and for prophylaxis purposes, the majority were unfamiliar with deprescribing strategies and rarely reviewed ongoing indications. Sufficient knowledge is correlated with recent literature reviews and medical specialty affiliation.

BACKGROUND

• The study aims to evaluate physician prescribing patterns, assess their knowledge of proton pump inhibitors, and identify factors influencing their knowledge.

BACKGROUND

• An online survey of Latin American and Spanish physicians assessed proton pump inhibitor usage patterns and case-scenario responses, categorizing knowledge, and conducting subgroup analysis based on training, experience, specialty, and literature review timing.

BACKGROUND

• Thirty-eight percent of surveyed physicians commonly prescribed proton pump inhibitors, and among them, 80% were unfamiliar with deprescribing strategies, with 54.4% rarely reviewing ongoing indications.

BACKGROUND

• Sufficient knowledge was correlated with recent literature reviews and medical specialty affiliations.

Unexplained abdominal pain as a driver for inappropriate therapeutics: an audit on the use of intravenous proton pump inhibitors

Background. Proton pump inhibitors (PPIs) are currently the most effective agents for acid-related disorders. However, studies show that 25–75% of patients receiving intravenous PPIs had no appropriate justification, indicating high rates of inappropriate prescribing.

Objective. To examine the appropriate use of intravenous PPIs in accordance with guidelines and the efficacy of a prescribing awareness intervention at an Asian teaching institution.

Setting. Prospective audit in a tertiary hospital in Malaysia.

Method. Every 4th intravenous PPI prescription received in the pharmacy was screened against hospital guidelines. Interventions for incorrect indication/dose/duration were performed. Patients’ demographic data, medical history and the use of intravenous PPI were collected. Included were all adult inpatients prescribed intravenous PPI.

Main Outcome Measure. Proportion of appropriate IV PPI prescriptions.

Results. Data for 106 patients were collected. Most patients were male [65(61.3%)], Chinese [50(47.2%)], with mean age ± SD = 60.3 ± 18.0 years. Most intravenous PPI prescriptions were initiated by junior doctors from the surgical [47(44.3%)] and medical [42(39.6%)] departments. Only 50/106(47.2%) patients had upper gastrointestinal endoscopy/surgery performed to verify the source of bleeding. Unexplained abdominal pain [81(76.4%)] was the main driver for prescribing intravenous PPIs empirically, out of which 73(68.9%) were for suspected upper gastrointestinal bleed. Overall, intravenous PPI was found to be inappropriately prescribed in 56(52.8%) patients for indication, dose or duration. Interventions on the use of intravenous PPI were most effective when performed by senior doctors (100%), followed by clinical pharmacists (50%), and inpatient pharmacists (37.5%, p = 0.027).

Conclusion. Inappropriate intravenous PPI usage is still prevalent despite the enforcement of hospital guidelines. The promotion of prescribing awareness and evidence-based prescribing through education of medical staff could result in more judicious use of intravenous PPI and dose-optimization.

Inhibition of lysosomal enzyme activities by proton pump inhibitors

BACKGROUND

Proton pump inhibitors (PPIs) are pro-drugs requiring an acidic pH for activation. The specificity of PPI toward the proton pump is mainly due to the extremely low pH at the parietal cell canalicular membrane where the pump is located. Reactivity of PPIs was also observed in moderately acidic environments like the renal collecting duct. But no PPI effect on lysosomal enzymes has been observed possibly because the previous studies were performed with liver tissue, where PPIs are metabolized.

METHODS

The reactivity of PPIs (omeprazole, lansoprazole and pantoprazole) with a cysteine-containing peptide was analyzed by mass spectrometry, and the impact of PPIs on lysosomal enzymes was evaluated in cultured cells and mice. The effect of PPIs on the immune system was examined with a mouse tumor immunotherapy model.

RESULTS

Incubation of a cysteine-containing peptide with PPIs at pH5 led to the conversion of most of the peptide into PPI-peptide adducts. Dose dependent inhibition of lysosomal enzyme activities by PPIs was observed in cultured cells and mouse spleen. Further, PPI counteracted the tumor immunotherapy in a mouse model.

CONCLUSIONS

Our data support the hypothesis that many of the PPI adverse effects are caused by systematically compromised immunity, a result of PPI inhibition of the lysosomal enzymes. This novel mechanism complements the existing mechanisms in explaining the increased incidence of tumorigenesis and infectious diseases among PPI users and underlie the ongoing concern about the overuse of PPIs in adult and pediatric populations.

Variables associated with stress ulcer prophylaxis misuse: a retrospective analysis

BACKGROUND

Stress ulcer prophylaxis (SUP) is commonly used in hospitals. Although its indications are better delineated for intensive care unit (ICU) patients, its use in non-ICU settings is somewhat arbitrary and based on judgment.

OBJECTIVE

We attempted to assess the extent of SUP overuse in our hospital. We also carefully collected and analyzed several variables to detect associations governing this flawed behavior and its financial burden on the hospital's budget.

MATERIALS AND METHODS

We retrospectively analyzed charts of patients admitted to the medical floor of a tertiary referral university hospital over a 1 year period. All adult patients admitted to the medical ward who received at least one dose of SUP were included and reviewed for a multitude of variables in addition to the appropriateness of acid suppression therapy (AST).

RESULTS

We included 320 charts and found that 92% of patients admitted during that period were not eligible for SUP. The total inappropriateness of SUP was noted to be 58% (p = 0.015). Increasing age and male gender were found to be significant variables in AST misuse (p = 0.045 and p = 0.010), much like duration of hospital stay (p = 0.008). Comorbidities was also found to be a defining variable for AST overuse (odds ratio [OR] = 3.27). Patients with two or more minor risk factors were also subjected more to SUP inappropriately (OR = 3.53), in addition to patients of certain specialties (Neurology, Infectious Diseases, etc.). Our calculated financial burden was more than $23,000 per year for the medical floor.

CONCLUSION

This retrospective study confirmed the growing suspicion that SUP misuse is evident on the medical floors. We also delineated several factors and variables associated with and affecting SUP overuse.

Inappropriate utilization of intravenous proton pump inhibitors in hospital practice--a prospective study of the extent of the problem and predictive factors

BACKGROUND

Intravenous (IV) proton pump inhibitors (PPI) reduce rebleeding from high-risk peptic ulcers following endoscopic therapy. The majority of IV PPI prescriptions in US hospital practice are inappropriate, leading to unnecessary drug costs, drug shortages and potential adverse events. To date, little is known about UK hospital IV PPI prescribing practice.

AIMS

To examine IV PPI use in a large university teaching hospital to determine factors predicting inappropriate prescribing practices.

METHODS

Prospective study of 276 recently hospitalized patients initiated on IV PPI over a 6-month period. IV PPI use was deemed appropriate for the following indications: endoscopic evidence of recent upper gastrointestinal (UGI) haemorrhage, patient nil by mouth with a valid indication for oral PPI therapy and stress ulcer prophylaxis in a critical care setting.

RESULTS

The majority (208/276, 75.4%) of IV PPI prescriptions were deemed inappropriate in terms of either indication for use, dose or duration of therapy. The majority (168/276, 60.9%) of prescriptions were initiated on non-medical wards. Inappropriate prescribing was more common amongst female patients, surgical admissions, non-UGI haemorrhage cases and when initiated by junior hospital doctors. Surgical admission [odds ratio (OR) 2.88, 95% confidence interval (CI) 1.12-7.42] and female gender [OR 3.92 (95% CI 1.84-8.34)] were independently predictive of inappropriate use.

CONCLUSION

This study suggests that the majority of IV PPI prescriptions in hospital are inappropriate, particularly when initiated for non-UGI bleeding indications. Improving prescribing awareness through education of junior medical staff on non-medical wards could reduce inappropriate IV PPI use.

Clinical and cost impact of intravenous proton pump inhibitor use in non-ICU patients

AIM: To assess the appropriateness of the indication and route of administration of proton-pump-inhibitors (PPIs) and their associated cost impact.

METHODS: Data collection was performed prospectively during a 6-mo period on 340 patients who received omeprazole intravenously during their hospital stay in non-intensive care floors. Updated guidelines were used to assess the appropriateness of the indication and route of administration.

RESULTS: Complete data collection was available for 286 patients which were used to assess intravenous (IV) PPIs utilization. Around 88% of patients were receiving PPIs for claimed stress ulcer prophylaxis (SUP) indication; of which, only 17% met the guideline criteria for SUP indication, 14% met the criteria for non-steroidal-anti-inflammatory drugs-induced ulcer prophylaxis, while the remaining 69% were identified as having an unjustified indication for PPI use. The initiation of IV PPIs was appropriate in 55% of patients. Half of these patients were candidates for switching to the oral dosage form during their hospitalization, while only 36.7% of these patients were actually switched. The inappropriate initiation of PPIs via the IV route was more likely to take place on the medical floor than the surgical floor (53% vs 36%, P = 0.003). The cost analysis associated with the appropriateness of the indication for PPI use as well as the route of administration of PPI revealed a possible saving of up to $17 732.5 and $14 571, respectively.

CONCLUSION: This study highlights the over-utilization of IV PPIs in non-intensive care unit patients. Restriction of IV PPI use for justified indications and route of administration is recommended.

Use of intravenous proton-pump inhibitors in a teaching hospital practice

OBJECTIVE

To evaluate intravenous proton-pump inhibitor (IV PPI) prescribing in a single academic teaching hospital.

METHODS

A retrospective pilot study of 107 patients in a single United States military teaching hospital was conducted over a 1-month period. Clinical data were collected and analyzed for demographic features, prior medication use, admission hemoglobin level, service prescribing the IV PPI, indication for IV PPI, IV PPI treatment duration, gastroenterology consultant use, endoscopic findings, and blood products given. Indications for use were compared with current established guidelines to determine appropriate usage.

RESULTS

A total of 683 doses of IV pantoprazole were prescribed over a 1-month period. Seventy-six patients (71%; 95% confidence interval [CI], 62-79%) who received IV PPIs did not meet the criteria for an appropriate indication for use. Ninety-nine patients in the study (93%; 95% CI, 86-96%) met criteria for an acceptable dosage given. The most common appropriate indication given was stress ulcer prophylaxis in a high-risk setting (13%; 95% CI, 8-21%) with appropriate use of this indication 45% of the time (95% CI, 29-62%). IV PPIs were appropriately prescribed most often by the medical intensive care unit (66.7%; 95% CI, 43-84%) and least often by the surgical wards services (16%; 95% CI, 7-33%). No discernable indication was given in 52% of cases (95% CI, 43-62%), and patients were not actually nil per os in 46% of these instances (95% CI, 34-59%).

CONCLUSIONS

Intravenous PPI prescribing habits in this military hospital facility are poor. A multifaceted approach including physician/pharmacist education, IV PPI ordering templates, and a consensus medical position statement from a major gastroenterological or prominent medical association may lead to more appropriate use.

Proton pump inhibitors: actions and reactions

Proton pump inhibitors are the second most commonly prescribed drug class in the United States. The increased utilization of PPIs parallels the rising incidence of reflux disease. Owing to their clinical efficacy and relative lack of tachyphylaxis, PPIs have largely displaced H-2 receptor antagonists in the treatment of acid peptic disorders. The elevation of intragastric pH and subsequent alterations of gastric physiology induced by PPIs may yield undesired effects within the upper GI tract. The ubiquity of the various types of H(+), K(+)-ATPase could also contribute to non-gastric effects. PPIs may influence physiology in other ways, such as inducing transepithelial leak.

Appropriate proton pump inhibitor use among older adults: a retrospective chart review

BACKGROUND

Proton pump inhibitors (PPIs) are widely used, but not always with a clear indication. Nonindicated use is of particular concern among older adults, who may have multiple comorbidities and take more medications, increasing their risk for adverse drug reactions.

OBJECTIVE

This study examined the appropriateness of PPI use at an outpatient geriatric practice and the association between particular patient characteristics and appropriate use of these medications.

METHODS

This was a retrospective chart review of a group of randomly identified community-dwelling adults aged >or=65 years with a current prescription for a PPI (as of August 2006) from a geriatric ambulatory care practice within an urban academic medical center. The main outcome was appropriateness of PPI use, categorized as indicated, possibly indicated, or not indicated, based on US Food and Drug Administration-approved indications and national gastroenterology guidelines.

RESULTS

Out of approximately 2500 patients in the geriatric practice, 702 (approximately 28%) were identified as having a current prescription for a PPI. From these, 110 charts were randomly selected for review, of which 10 were excluded based on predefined criteria. The sample was 79% female and 46% white, with a mean age of 82.8 years (range, 66-99 years). PPI use was indicated in 64% of these patients, possibly indicated in 7%, and not indicated in 29%. Compared with indicated PPI use, nonindicated use was significantly associated with use for <1 year (relative risk = 2.20; 95% CI, 1.00-4.86; P = 0.05). Nonindicated PPI use was not significantly associated with age, female sex, nonwhite race, or PPI initiation in the inpatient setting.

CONCLUSION

Almost 30% of patients receiving a PPI in this academic geriatric practice had no documented indication for PPI use.