Awareness of the inappropriate use of GI prophylaxis and its cost. Adverse effects of proton pump inhibitor

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2 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 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

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

5 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 * 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 Heidelbaugh and Inadomy in % 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 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

7 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

8 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)

9 NONE!!!

10 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

11 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

12 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 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

14 ED/Clinic Admissions (N = 50) PPI ordered on admission (N = 32)(64%) PPI not ordered on admission (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 (N=1) Do not meet PPI inidcation (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

15 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

16 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

17 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