Presentation on theme: "“Should I add a PPI?” A review of inpatient GI prophylaxis"— Presentation transcript:
1“Should I add a PPI?” A review of inpatient GI prophylaxis Lenny Noronha, MDAssociate Professor, Hospitalist Section2/5/10
2Case 1 Mrs. Lowdee 78yf POD 2 s/p L hip ORIF Consult for opiate-rel deliriumChanged to toradol 15mg IV q8hNurse calls for am lab drop in H/H.“I did that to her.”‘Maybe I should have put her on a PPI…’
3Case 2Dr. 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.
5Thanks to Rush Pierce, MD Jim Little, RN David Hedberg Kendall Rogers, MDSanjeev Arora, MD
6Objectives Review current appropriate use of GI prophylaxis Discuss literature of riskDisplay UNM IM use, concerns
7Underlying Concepts Efficacy:Harm, Perceived Safety, Cost, Estrogen, Bb, Bisphosphonates, Statins (Taylor)Extrapolation (ICU -> SAC/ward)Dangers of templates, following patterns of supervisors/peers
8Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients Volume 330:February 10, 1994Number 6Risk Factors for Gastrointestinal Bleeding in Critically Ill PatientsDeborah J. Cook, Hugh D. Fuller, Gordon H. Guyatt, John C. Marshall, David Leasa, Richard Hall, Timothy L2252 patients > 16 yo adm to med/surg ICU’s in 4 academic medical centersRisk of “clinically important” bleeding in “critically ill”
9Risk Factors for Clinically Important Bleeding among 2252 Patients Admitted to an Intensive Care UnitTable 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.
10Risk Factors for ICU UGIB* Mechanical ventilation > 48 hoursCoagulopathyINR > 1.5Platelets < 50KUGIB within past yearChronic Liver, Kidney Disease+/- Steroids* Multiple meta-analyses
11Outside the ICUQuadeer 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 1Retrospective 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
12PPI, H2, Sucralfate, Maalox? Efficacy over placebo for all agents establishedShuman 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):519-27Decreased incidence in clinically significant UGIB and mortality with PPI over H2, other agents.Conrad SA, et al, Critical Care Med, Apr 2005; 33(4);
13Risk of Harm DataRisk 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: /ajgHAP: 63, 878 non-ICU admissions over 3 days in an academic medical center. “pharmacoepidemiologic cohort study”Thank sub-I John KennedyHAP: 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%
14Authors’ comments: 33,000 preventable US deaths! Rates of Hospital-Acquired Pneumonia According to Acid-Suppressive Medication StatusHerzig, 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 111180,000 HAP, 18% mortalityAuthors’ comments: 33,000 preventable US deaths!Copyright restrictions may apply.
15Other suggested risks… C. diffEnteric infections (salmonella, campylobacter)Hip fractureB12 deficiencyDecreased absorption of B12, iron and calciumGastric, colon polypsLong-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:
16Cost (per dose) Nexium PO $6.19 $14.90 Protonix PO $4.79 $12.12 DrugCost to UNMPatient ChargeNexium PO$6.19$14.90Protonix PO$4.79$12.12Protonix IV$28.20$67.60
18ICU vs SAC/Wards 2009 PPI Use 72% of ICU pts on PPICardiology excluded- 72% of ICU pts on PPI- Cardiology excluded
19Appropriate GI Prophylaxis with PPI Ventilated, coagulapathic or therapeutically anticoagulated critically ill patientsContinue PPI on outpatient usersConsider potential absorption effects (Ca, Fe, etc)What about Plavix patients?Stay tuned for guidelines updates, quality marker implementation
20Plan of Attack This talk Change Inpatient Provider Progress Note Remove “Nutrition/GI prophylaxis” promptEmpower Clinical PharmacistsReport 2010 Q1 IM use at May business meeting