GI prophylaxis - Should I order it or not -

Objective Understand the indication for stress ulcer/GI prophylaxis Awareness of the inappropriate use of GI prophylaxis and its cost Adverse effects of proton pump inhibitor

Which of followings require GI prophylaxis 65yo w/ HTN and ESRD on HD p/w left hip fracture, who was kept NPO for the past 3 days due to delaying in surgery schedule. 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation. 18yo male w/ type I DM p/w severe abd pain, nausea and vomiting x 2 days, admitted to ICU for DKA secondary to non-compliance. 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation. 59yo active drinker w/ hep C cirrhosis admitted for monitoring of withdrawal symptoms. INR 1.3, platelets90, albumin 2.8, PTT normal ,and bilirubin 2. None of the above These are all real cases. Answer and explanation will be on slide 11 … F (none of these requires GI ppx)

GI / Stress ulcer Pathophysiology Complication Treatment Impaired gastric mucosal protection from poor perfusion caused by intense physiologic stress Hypersecretion of gastric acid Complication Overt GI bleeding: Usually shallow and from capillary bed 1.5-8.5% in all ICU patients Up to 15% if no GI prophylaxis Perforation: Rare. < 1% in SICU patients Treatment PPI > H2 blocker > Sucralfate = antacid

Inappropriate use of GI prophylaxis 26.8% - 71% patients on medicine wards were placed on GI ppx 56% - 69% of patients received GI ppx with no indications 54% - 58% of patients receiving inappropriate GI ppx were discharged with acid suppressive medications Only 33% - 37.1% received GI ppx with appropriate indications However, several trials have shown the inappropriate use of GI prophylaxis * Grube RR and May DB, “Stress ulcer prophylaxis in hospitalized patients not in internsive care units”. Am J Health-Syst Pharm. Vol 64 Jul 1, 2007.

Economic effects Heidelbaugh and Inadomy in 2006 Wadobia et al in 1997 22% of 1,769 pts received inappropriate GI ppx 54% of these were d/c’d home with meds $11,000 over 4 months period Estimated annual cost of inappropriate GI ppx was > $111,000 Wadobia et al in 1997 45 of 88 ICU patients received inappropriate GI ppx $5,084.31 for inpatient and $8,619.75 for outpatient Erstad et al in 1997 $2,272 = per-pt drug cost before inservice training for appropriate GI ppx $1,417 = after inservice training (opening sentence) As the result of the inappropriate use, a substantial amount of healthcare dollars are wasted - Wadobia looked at 88 patients with the inappropriate GI ppx in ICU - Erstad compared the cost of inappropriate GI ppx before and after inservice training on appropriate GI ppx

Potential side effects of PPI C diff-associated diseases (CDAD) Increased risk of community acquired and nosocomial pneumonia Prolonged hypergastrinemia Gastric atrophy Chronic hypochlohydria Increased risk of fractures Hypomagnesemia Iron and B12 malabsorption Interaction with Plavix Other than cost issues, GI ppx medication such as PPI has its own potential side effects

GI prophylaxis in ICU Major risk (need at least 1) Minor risk (need > 2) Coagulopathy (INR > 1.5, Plt < 50K, or PTT > 2x normal) Mechanical ventilation > 48hrs GI ulceration or bleeding within the past year Traumatic brain or spinal cord injury Severe burn (>35% of the body surface area) Sepsis ICU stay > 1 week Occult GI bleeding > 6 days High dose glucocorticoid therapy (>250mg hydrocortisone or equiv.) Enteral feeding (on case basis) So when do we use GI prophylaxis? On the left, the major risk includes …. You only need to have one of these On the right, if you have 2 or more of the following, the indication is met

GI prophylaxis on wards NONE !!! As for the medicine wards … there has not been any guidelines nor indications

Which of followings require GI prophylaxis 65yo w/ HTN and ESRD on HD p/w left hip fracture, who was kept NPO for the past 3 days due to delaying in surgery schedule. 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation. 18yo male w/ type I DM p/w severe abd pain, nausea and vomiting x 2 days, admitted to ICU for DKA secondary to non-compliance. 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation. 59yo active drinker w/ hep C cirrhosis admitted for monitoring of withdrawal symptoms. INR 1.3, platelets90, albumin 2.8, PTT normal ,and bilirubin 2. None of the above Again … these are all real cases that are put on GI ppx inappropriately

Answer None of the above 65yo w/ HTN and ESRD on HD p/w left hip fracture, who was kept NPO for the past 3 days due to delaying in surgery schedule. 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation. 18yo male w/ type I DM p/w severe abd pain, nausea and vomiting x 2 days, admitted to ICU for DKA secondary to non-compliance. 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation. 59yo active drinker w/ hep C cirrhosis admitted for monitoring of withdrawal symptoms. INR 1.3, platelets90, albumin 2.8, PTT normal ,and bilirubin 2. None of the above These are all real cases that were put on PPI for GI ppx inappropriately No indication on wards. Intubation < 48 hours ICU stay projected to be less than 6 days and no other major or minor indications met. Low dose dexamethasone will not need GI ppx No indication on wards. No coagulopathy

Summary GI prophylaxis is very often ordered inappropriately (50-70%) Cost of these inappropriate usage is substantial There is no indication to order GI ppx on general medicine wards! Selected ICU patients should be placed GI ppx but not all

50 ED/clinic admissions in a single month period UCI pilot study Goal: Evaluation misusage of GI prophylaxis with PPI and the cost in UCI Medicine ward 50 ED/clinic admissions in a single month period Retrospective study via chart review Indication to order acid suppression meds Continuation of home medication H/o GERD, gastritis, GI bleeding, or presenting symptoms concerning for above diseases We did a small study at UCI too look into the inappropriate use GI ppx

Result ED/Clinic Admissions (N = 50) PPI ordered on admission (N = 32)(64%) Home med (N=13)(26%)* Discharge with PPI (N=10) Meet PPI indication (N=20)(40%) Do not meet PPI indication (N=12)(24%) Discharge with PPI (N=1) PPI not ordered on admission (N = 18)(36%) Meet PPI indication (N=1) Discharge with PPI (N=0) Do not meet PPI inidcation (N = 17) - Indications = continuation of home medication, had Dx of acid related diseases such as GERD, GI bleed, ulcer, NSAID induced ulcer, ZES - All patients were started on IV protonix - If not counting “continue home medication” group, the % of inappropriate usage / “do not meet” = 12 / (50-13) = 34% * There were 5-7 patients who were placed on PPI as outpatient without indications

Cost of Protonix (to UCI) Inpatient Outpatient 40mg IV = $3.75/inj 40mg PO = $0.22/tab 20mg PO = $0.1/tab 40mg PO = $0.05 /tab 20mg PO = < $0.05/tab

Result/Conclusion 12 out of 50 (24%) admitted patients were placed on PPI inappropriately If not counting the “continuation of home medication group”, the % of inappropriate rises to 34% Total cost of inappropriate PPI orders: $45/day 10 cups of coffee 4 drinks 5-8 meals in cafeteria $1,350/month > 1/3 of resident monthly salaries Combine what we found and the cost of protonix

Future direction Implementation of prior authorization of ordering PPI starting in Feb, 2012 Compare of pre and post implementation on all ward admissions Raise awareness of the appropriate GI ppx indication and the cost of inappropriate usage Analyze ICU admissions, transfers from ICU and OSH Create UCI guideline