Acid Suppressive Therapy for Stress Ulcer Prophylaxis in Noncritically Ill Patients

Proton pump inhibitors in inpatients: Are we getting it right? A retrospective analysis

Background

Proton pump inhibitors (PPIs) are commonly prescribed to hospitalized patients, but many of these prescriptions may not be based on evidence-based indications. It's important to understand that inappropriate prescribing of PPIs can lead to unnecessary medications and financial burdens. Unfortunately, there are not many recent studies exploring how often PPIs are prescribed and if they are being prescribed appropriately.

Objective

The study aimed to assess the appropriateness of PPIs use among hospitalized patients. It evaluated the indications for PPIs use and determined whether the use of PPIs in hospitalized patients is justified or not.

Setting

The study was conducted at Hamad General Hospital, a tertiary academic healthcare center in the state of Qatar.

Methods

A retrospective observational study with 201 subjects, was conducted in general internal medicine wards at a tertiary hospital. Physician documentation and inpatient and outpatient medication prescriptions were analyzed for PPIs exposure.

Main outcome measures

The appropriateness of exposure to PPIs is determined based on international recommendations.

Results

Of 533 hospitalized patients who were not critically ill, 201 (37.7%) were prescribed PPIs. The study found that 65.2% of the patients had no valid indication for PPIs exposure. Furthermore, 18% of patients were inappropriately prescribed stress ulcer prophylaxis with PPIs even though they had a low risk for the development of ulcer disease. After discharge, 82.6% of patients were prescribed PPIs, with the most common indication (43%) being gastrointestinal ulcer prophylaxis.

Conclusion

This study sheds light on the issue of overutilization of PPIs, specifically in non-critically ill hospitalized patients. It highlights the unnecessary continuation of PPI prescriptions at discharge and emphasizes the importance of physicians reevaluating PPI prescriptions periodically to ensure they are still necessary and discontinuing them when possible to avoid unwanted consequences.

Appropriateness of proton pump inhibitors use in noncritically ill hospitalized children in a tertiary hospital in Saudi Arabia

Background

Studies assessing the appropriate use of proton pump inhibitors (PPIs) for hospitalized noncritically ill pediatric patients are lacking. Therefore, this study aimed to assess the suitability of PPI prescriptions in noncritically ill pediatric patients.

Methods

This cross sectional retrospective study was conducted at a maternity hospital in Qassim, Saudi Arabia from November 2020 to January 2021. All noncritically ill hospitalized children aged 14 years and below who received PPIs were included. The endpoints included the number and percentage of patients who appropriately received PPIs in general and in each age category. The collected data were analyzed using Microsoft Excel (version 2208, Microsoft Corp., Redmond, WA, USA).

Results

In total, 332 medical records were screened, of which 246 were included. Of all patients, 49.2% were children and 50.8% were infants, with the average age at admission being 5.39 ± 5.4 years years. More than half of the patients were female, and the average weight of patients was 19.8 kg. Omeprazole was appropriately used in 95 (38.5%) patients. Based on age groups, omeprazole was appropriately used in 66.3% of children and 38.4% of infants.

Conclusion

The use of omeprazole in noncritically ill pediatrics was only deemed appropriate in 38.6% of the study population. This result indicates that this medication was overused in the institution. Additional research is required to confirm this on a nationwide scale.

Involvement of microRNA/cystine/glutamate transporter in cold-stressed gastric mucosa injury

Stress ulcers are complicated by severe trauma and other critical diseases, the mechanism of which remains unclear. An increasing number of studies have shown that microRNAs (miRNAs) are important regulators of stress responses such as hypoxia, abnormal temperature, and inflammation. The evidence indicates that miRNAs are also involved in regulating stress-induced ulcers. Recently, we demonstrated that gastric mucosal injury induced by aspirin is related to the reduction of glutamate levels by inhibition of cystine/glutamate transporter (xCT) activity. In the present study, the effect of a miRNA/xCT on gastric mucosal injury induced by cold stimulation was investigated. We found that cold stimulation induced gastric mucosa injury with a reduction in glutamate levels and xCT activity and upregulation of miR-143, miR-152, and miR-181 expression. Exogenous glutamate significantly alleviated gastric mucosa injury by cold stimulation. In vitro experiments demonstrated that treatment with miR-143, miR-152, or miR-181 mimics directly induced cell damage. The effects of these mimics were alleviated by exogenous glutamate. The present study suggests that miR-143, miR-152, and miR-181 are involved in cold stimulation-induced acute gastric mucosal injury. Furthermore, the regulatory effect of miRNAs on gastric mucosa injury induced by cold stimulation is related to a decrease in glutamate release by reduction of cystine/glutamate transporter activity.

Current Practice of Stress Ulcer Prophylaxis in Surgical Departments in Mecklenburg Western Pomerania, Germany

Background: Despite the growing concern over its potentially severe side effects and considerable economic burden, stress ulcer prophylaxis (SUP) is still frequently prescribed to patients in medical non-intensive care units. Recent data indicate that the situation is similar in surgical departments. Currently, data on the concepts within and regulation of routine SUP practice in surgical departments are sparse. The present study was designed to examine the current practice of SUP in Mecklenburg West Pomerania, Germany, and to identify possible reasons for the dissociation of medical literature and clinical practice. Methods: A questionnaire-based survey was conducted to elucidate current SUP practices in surgical departments of acute care hospitals in Mecklenburg Western Pomerania, Germany. Results: In most surgical departments (68%), a standard operating procedure (SOP) for SUP had not been developed. In departments with an existing SOP, 47.6% of responding medical staff members (MSM) with prescribing authority did not know of its existence. Of the MSMs aware of the existence of an SUP-SOP, only 42.9% indicated that they were familiar with its content. Critical re-evaluation of SUP indications upon transfer from the intensive care unit (ICU) to the general hospital ward (GHW) and before hospital discharge was performed frequently or systematically by only about half of the responding MSMs. Discussion: In the face of continued massive over-prescription of SUP in the perioperative routine, the development of easy-to-use local guidelines and their strict implementation in the clinical routine, as well as intensified medial education on this subject, may be effective tools to reduce acid-suppressive medication (ASM) associated side effects and economic burden.

Current practice of stress ulcer prophylaxis in a surgical patient cohort in a German university hospital

Introduction

Stress ulcer prophylaxis (SUP) has been a widespread practice both in intensive care units (ICU) and internal wards at the beginning of the twenty-first century. Clinical data suggests an important overuse of acid suppressive therapy (AST) for this indication. Data on current clinical practice of SUP in surgical patients in a non-ICU setting are spares. In the light of a growing number of reports on serious side effects of AST, this study evaluates the use of AST for SUP in a normal surgical ward in a German university hospital.

Methods

Between January 2016 and June 2016, SUP was analysed retrospectively in 1132 consecutive patients of the Department of Surgery of the Universitätsmedizin Greifswald.

Results

The patients managed with and without SUP were similar with respect to demographic data and treatment with anticoagulants, SSRI and glucocorticoids. Patients with SUP were treated more frequently by cyclooxygenase inhibiting drugs (NSAID, COX2-inhibitors), were more frequently treated in the intermediated care unit and had a longer hospital stay. Risk factors for the development of stress ulcers were similarly present in patient groups managed with and without SUP. About 85.7–99.6% of patients were given SUP without an adequate risk for stress ulcer development, depending on the method used for risk assessment.

Discussion

Still today, SUP is widely overused in non-ICU surgical patients. Information campaigns on risk factors for stress ulcer development and standard operating procedures for SUP are required to limit potential side effects and increased treatment costs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02325-3.

Proton pump inhibitors and 180-day mortality in the elderly after Clostridium difficile treatment

Background

There is a reported association between proton pump inhibitor (PPI) exposure and increased risk of Clostridium difficile infection (CDI), but less is known about how this class of medications taken during treatment might influence mortality after CDI. Here we examine 180-day mortality rates in a cohort of CDI elders and its association with exposure to PPIs. We conducted a retrospective cohort study of elderly patients (> 65 years of age) diagnosed and treated for CDI in the years 2014–2016 (n = 874) in the Umass Memorial Health Care system, which represents both academic and community healthcare. Patient characteristics and medication use was extracted from the electronic medical record (EMR) and 6 month mortality data was obtained via the Center for Disease Control National Death Index. A Cox proportional hazards model was used to estimate hazard ratios associated with medication exposures and other relevant variables.

Results

Of the 874 elderly adults treated for CDI, 180-day all-cause mortality was 12.4%. Exposure to a PPI was associated with a 55% reduced risk of mortality (adjusted hazard ratio (aHR) 0.45; 95% confidence interval (CI) 0.28–0.72). In our Cox model, increasing age (aHR 1.45; 95% CI 1.14–1.84), those with severe CDI infections (aHR 1.87; 95% CI 1.22–2.88), and those with hospital acquired CDI (aHR 3.01; 95% CI 1.81–4.99) also had increased 180 day mortality risk. There were similar associations noted with both 90 day and 1-year mortality.

Conclusion

Use of PPIs during CDI treatment in elderly patients is associated with decreased 180-day mortality. Although use of PPIs has been associated with an increased risk of CDI, it appears to be protective against mortality when used during the treatment phase.

Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit

Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Agents that suppress gastric acid are commonly prescribed to reduce the incidence of clinically important stress ulcer-related gastrointestinal bleeding. However, the indiscriminate use of stress ulcer prophylaxis in all patients admitted to the intensive care unit is not warranted and can have potential adverse clinical effects and cost implications. The present guidelines from the Sociedade Portuguesa de Cuidados Intensivos summarizes the current evidence and gives six clinical statements and an algorithm aiming to provide a standardized prescribing policy for the use of stress ulcer prophylaxis in the intensive care unit.

Appropriateness of Acid-suppressing Agents for Stress Ulcer Prophylaxis in Non-intensive Care Unit Setting in Saudi Arabia

Objective

To investigate the appropriateness of acid-suppressive therapy (AST) for stress ulcer prophylaxis (SUP) in noncritically ill hospitalized patients.

Materials and Methods

A prospective, observational study with 384 subjects was conducted between October and December 2017 in the emergency and internal medicine departments. The Herzig clinical risk scoring system and the guidelines of the American Society of Health-System Pharmacists guidelines were used to assess risk factors and determine risk scores for gastrointestinal (GI) bleeding.

Results

The mean age of subjects was 51.9 ± 19.4 years, and 220 (57.3%) of them were males. Among the absolute risk factors, coagulopathy was observed in 2 (0.5%) patients, mechanical ventilation in 15 (3.9%), and a history of GI bleeding in 1 (0.3%). Of 384 patients with SUP, 370 (96.4%) had a clinical risk score ≤ 9 and 14 (3.6%) had a risk score between 10 and 12 for nosocomial GI bleeding. A statistically significant relationship was found between the risk factor indication and demographics.

Conclusion

SUP is frequently administered to noncritically ill hospitalized patients lacking risk factors for GI bleeding. Proton pump inhibitors are the overwhelming first choice of AST among prescribers. Practitioners should follow international guidelines when prescribing ASTs outside the critical-care setting.

Prophylactic Acid-Suppressive Therapy in Hospitalized Adults: Indications, Benefits, and Infectious Complications

Acid-suppressive therapy for prophylaxis of stress ulcer bleeding is commonly prescribed for hospitalized patients. Although its use in select, at-risk patients may reduce clinically significant gastrointestinal bleeding, the alteration in gastric pH and composition may place these patients at a higher risk of infection. Although any pharmacologic alteration of the gastric pH and composition is associated with an increased risk of infection, the risk appears to be highest with proton pump inhibitors, perhaps owing to the potency of this class of drugs in increasing the gastric pH. With the increased risk of infection, universal provision of pharmacologic acid suppression to all hospitalized patients, even all critically ill patients, is inappropriate and should be confined to patients meeting specific criteria. Nurses providing care in critical care areas may be instrumental in screening for appropriate use of acid-suppressive therapy and ensuring the drugs are discontinued upon transfer out of intensive care or when risk factors are no longer present.

Preventive effect of prospective evaluation combined with graded prevention on stress ulcer in emergency patients

AIM

To evaluate the effect of prospective evaluation combined with graded prevention on the incidence of stress ulcer in emergency patients.

METHODS

From January 2011 to June 2013, 142 emergency patients treated at our hospital were included in a control group and given normal intervention, while 163 emergency patients treated from July 2013 to January 2016 at our hospital were included in an observation group and given prospective evaluation combined with graded intervention. The incidence of stress ulcer, bleeding time, length of stay and satisfaction rate were compared between the two groups.

RESULTS

The incidence of stress ulcer was significantly lower in the observation group than in the control group (13.49% vs 32.39%, P < 0.05). The bleeding time and hospital stay were significantly shorter in the observation group than in the control group (2.65 d ± 2.43 d vs 4.27 d ± 2.01 d, 17.44 d ± 8.67 d vs 22.67 d ± 7.95 d, P < 0.05). Of the 163 patients in the observation group, 97 were very satisfied, 57 were moderately satisfied, 4 were satisfied, and 5 were not satisfied with the intervention. Of the 142 patients in the control group, 59 were very satisfied, 55 were moderately satisfied, 18 were satisfied, and 10 were not satisfied with the intervention. The rate of satisfaction with the intervention was significantly higher in the observation group than in the control group (94.46% vs 80.27%, P < 0.05).

CONCLUSION

Prospective evaluation combined with graded prevention can significantly reduce the incidence of stress ulcer, shorten bleeding time and hospitalization time, and improve patient satisfaction in emergency patients.

Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression

BACKGROUND

The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications.

METHODS

The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence.

RESULTS

Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile.

CONCLUSIONS

Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .

Clinical Outcomes of Acid Suppressive Therapy Use in Hematology/Oncology Patients at an Academic Medical Center

Background: Acid suppressive therapy (AST)—namely, proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs)—is routinely prescribed to hospitalized patients for stress ulcer prophylaxis (SUP). Objective: To identify the incidence of and indications for AST use in the hematology/oncology population as well as to identify the occurrence of the following PPI-associated adverse events: pneumonia and Clostridium difficile–associated diarrhea (CDAD). Methods: A retrospective chart review was conducted on adult hematology/oncology patients admitted to any oncology service for ≥48 hours from October 1, 2014, to December 31, 2014. Results: Of the 298 patients who met the inclusion criteria, 73% (n = 218) received an AST during admission. The most common indication for an AST was SUP (63%). The incidence of hospital-acquired pneumonia (HAP) was 10%, 0%, and 4% in patients who received a PPI, H2RA, and no AST, respectively (14/142 vs 0/70 vs 3/80; odds ratio [OR] for PPI vs no AST = 2.68; 95% CI = 0.75-9.63). The incidence of CDAD was 3%, 1.3%, and 1.2% in patients who received a PPI, H2RA, and no AST, respectively (4/142 vs 1/70 vs 1/80; OR for PPI vs H2RA = 1.92; 95% CI = 0.21-17.47). Conclusion: This is the first study to describe the incidence of and indications for AST use in the hospitalized hematology/oncology population. There was a high occurrence of AST use, particularly PPIs, in these patients at our institution. Additionally, there was a trend toward an increased risk of HAP and CDAD in patients who received AST during admission.