1. “Should I add a PPI?” A review of inpatient GI prophylaxis
Lenny Noronha, MD
Associate Professor, Hospitalist Section
2/5/10

2. 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…’

3. 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.

5. Thanks to Rush Pierce, MD Jim Little, RN David Hedberg
Kendall Rogers, MD
Sanjeev Arora, MD

6. Objectives Review current appropriate use of GI prophylaxis
Discuss literature of risk
Display UNM IM use, concerns

7. Underlying Concepts Efficacy:Harm, Perceived Safety, Cost,
Estrogen, Bb, Bisphosphonates, Statins (Taylor)
Extrapolation (ICU -> SAC/ward)
Dangers of templates, following patterns of supervisors/peers

8. Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients
Volume 330:
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”

9. Risk Factors for Clinically Important Bleeding among 2252 Patients Admitted to an Intensive Care Unit
Table 4. 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.

10. 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

11. Outside the ICU
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
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.
Nonsignificant trend toward PPI benefit for patients on therapeutic anticoagulation or clopidogrel

12. 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):
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);

13. Risk of Harm Data
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:
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):
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: ; March 31, 2009; doi: /ajg
HAP: 63, 878 non-ICU admissions over 3 days in an academic medical center. “pharmacoepidemiologic cohort study”
Thank sub-I John Kennedy
HAP: 63, 878 non-ICU admissions over 3 days in an academic medical center. “pharmacoepidemiologic cohort study”
SBP: retrospective case-control study: chart review of 1193 pts with cirrhosis adm to hospital on PPI as outpt. 70 sbp patients age/severity/comorbidity matched to 70 without sbp or UGIB who had paracentesis. Of sbp pt’s 69% on PPI, 31%

14. Authors’ comments: 33,000 preventable US deaths!
Rates of Hospital-Acquired Pneumonia According to Acid-Suppressive Medication Status
Herzig, S. J. et al. JAMA 2009;301:
Half of patients on acid-suppressing medicine (83% PPI)
30% higher risk of HAP with PPI. Headline: highest risk in first 48hrs, seemed to decr with time.
NNH 111
180,000 HAP, 18% mortality
Authors’ comments: 33,000 preventable US deaths!
Copyright restrictions may apply.

15. Other suggested risks…
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, )
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:

16. Cost (per dose) Nexium PO $6.19 $14.90 Protonix PO $4.79 $12.12
Drug
Cost to UNM
Patient Charge
Nexium PO
$6.19
$14.90
Protonix PO
$4.79
$12.12
Protonix IV
$28.20
$67.60

17. 2009 Q3 UNMH PPI Use

18. ICU vs SAC/Wards 2009 PPI Use
72% of ICU pts on PPI
Cardiology excluded
- 72% of ICU pts on PPI
- Cardiology excluded

19. 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

20. 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

21. Thank you