Slide 2 Should I add a PPI? A review of inpatient GI prophylaxis
Lenny Noronha, MD Associate Professor, Hospitalist Section 2/5/10
Slide 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 Slide 4 Case 2 Dr. Coldfeet - 35ym a couple years out
of residency - Notices housestaff, colleagues use PPIs left and
right for inpatient GI prophylaxis. - Not sure whether to adopt
practice Doesnt want partners to notice omission and gossip about
incompetence. Slide 5 Slide 6 Thanks to Rush Pierce, MD Jim Little,
RN David Hedberg Kendall Rogers, MD Sanjeev Arora, MD Slide 7
Objectives Review current appropriate use of GI prophylaxis Discuss
literature of risk Display UNM IM use, concerns Slide 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 Slide 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 330:377-381February 10, 1994Number 6 2252
patients > 16 yo adm to med/surg ICUs in 4 academic medical
centers Risk of clinically important bleeding in critically ill
Slide 10 Risk Factors for Clinically Important Bleeding among 2252
Patients Admitted to an Intensive Care Unit Conclusion: You dont
have to prophylax critically ill patients unless they have
coagulopathy or require mechanical ventilation. Slide 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
Slide 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 Slide 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): 562-7. Cook DJ, Stress ulcer prophylaxis in the critically
ill: a meta analysis Am J Med, Nov 1991; 91(5):519-27 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); 760-5. Slide 14 Risk of Harm Data Risk of
Community-Acquired Pneumonia and Use of Gastric AcidSuppressive
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: 1955 - 1960. 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):2120-2128.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: 1130-1134; March 31, 2009;
doi:10.1038/ajg.2009.80 HAP: 63, 878 non-ICU admissions over 3 days
in an academic medical center. pharmacoepidemiologic cohort study
Slide 15 Copyright restrictions may apply. Herzig, S. J. et al.
JAMA 2009;301:2120-2128. 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 111
180,000 HAP, 18% mortality Slide 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, 896-903) 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;296:2947-2953. Slide 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 Slide 18 2009 Q3 UNMH PPI Use Slide 19 ICU vs
SAC/Wards 2009 PPI Use - 72% of ICU pts on PPI - Cardiology
excluded Slide 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 Slide
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 Slide 22 Thank
you
