1. GI prophylaxis - Should I order it or not -

2. 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

3. 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)

4. 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
% in all ICU patients
Up to 15% if no GI prophylaxis
Perforation: Rare. < 1% in SICU patients
Treatment
PPI > H2 blocker > Sucralfate = antacid

5. 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% % 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.

6. 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, for inpatient and $8, 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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