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

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Presentation on theme: "“Should I add a PPI?” A review of inpatient GI prophylaxis Lenny Noronha, MD Associate Professor, Hospitalist Section 2/5/10."— Presentation transcript:

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

3 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…’

4 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.

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

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

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

9 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 Volume 330: February 10, 1994Number patients > 16 yo adm to med/surg ICU’s in 4 academic medical centers Risk of “clinically important” bleeding in “critically ill”

10 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.

11 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

12 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

13 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): 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);

14 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): Shoshana J. Herzig, MD; Michael D. Howell, MD, MPH; Long H. Ngo, PhD; Edward R. Marcantonio, MD, SM 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”

15 Copyright restrictions may apply. Herzig, S. J. et al. JAMA 2009;301: Rates of Hospital-Acquired Pneumonia According to Acid-Suppressive Medication Status Authors’ comments: 33,000 preventable US deaths! 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 ,000 HAP, 18% mortality

16 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:

17 Cost (per dose) DrugCost to UNMPatient Charge Nexium PO$6.19$14.90 Protonix PO$4.79$12.12 Protonix IV$28.20$67.60

18 2009 Q3 UNMH PPI Use

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

20 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

21 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

22 Thank you


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