• 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
A.
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.
B.
75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation
caused by community acquired pneumonia requiring 1 day of intubation.
C.
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.
D.
45yo female w/ HIV and found to have CBS lymphoma started on low dose
dexamethasone and palliative brain radiation.
E.
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.
F.
None of the above
• Pathophysiology
– 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
• 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
* Grube RR and May DB, “Stress ulcer prophylaxis in hospitalized patients not in internsive care units”. Am J HealthSyst Pharm. Vol 64 Jul 1, 2007.
• Heidelbaugh and Inadomy in 2006
–
–
–
–
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
• 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
Major risk (need at least 1)
• 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)
Minor risk (need > 2)
• Sepsis
• ICU stay > 1 week
• Occult GI bleeding > 6 days
• High dose glucocorticoid
therapy (>250mg
hydrocortisone or equiv.)
• Enteral feeding (on case
basis)
• NONE !!!
A.
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.
B.
75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation
caused by community acquired pneumonia requiring 1 day of intubation.
C.
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.
D.
45yo female w/ HIV and found to have CBS lymphoma started on low dose
dexamethasone and palliative brain radiation.
E.
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.
F.
None of the above
A.
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.
B.
75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation
caused by community acquired pneumonia requiring 1 day of intubation.
C.
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.
D.
45yo female w/ HIV and found to have CBS lymphoma started on low dose
dexamethasone and palliative brain radiation.
E.
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.
F. None of the above
• 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
• 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
ED/Clinic
Admissions
(N = 50)
PPI ordered on
admission
PPI not ordered
on admission
(N = 32)(64%)
(N = 18)(36%)
Home med
(N=13)(26%)*
Meet PPI
indication
(N=20)(40%)
Do not meet
PPI indication
(N=12)(24%)
Meet PPI
indication
Do not meet
PPI inidcation
(N=1)
(N = 17)
Discharge with
PPI (N=10)
Discharge with
PPI (N=10)
Discharge with
PPI (N=1)
Discharge with
PPI (N=0)
Discharge with
PPI (N=0)
* There were 5-7 patients who were placed on PPI as outpatient without indications
Inpatient
• 40mg IV = $3.75/inj
• 40mg PO = $0.22/tab
• 20mg PO = $0.1/tab
Outpatient
• 40mg PO = $0.05 /tab
• 20mg PO = < $0.05/tab
• 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
• 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