The Downward Spiral of Acid Suppressive Therapy in Stress Ulcer Prophylaxis

Abstract

Introduction: Acid suppressive therapy (AST) use for stress ulcer prophylaxis (SUP) have long been seen as medical lore even though well established guidelines on appropriate AST use exists. Studies on non-critically ill patients have shown that AST guidelines are not followed. AST is routinely misused, leading to inappropriate chronic use. Moreover, chronic proton pump inhibitor (PPI) use has complications such as enteric infections, pneumonia, osteoporosis and drug interactions. Critically ill patients have multiple factors that lead to increased morbidity and mortality, one of which is inappropriate medication uses. This study seeks to evaluate the common misuse of AST in critically ill patients, and identify associated risk factors. Methods: A retrospective study of 692 patients admitted to the critical care units (CCU) at an academic institution. Inclusion criteria were patients admitted to CCUs who were >18y/o, and started on AST. Study excluded patients admitted with GI bleed, transferred to an outside institution, or expired. Data collection include, APACHE score, AST at home, indications for AST based on ASHP guidelines, AST discontinued when no longer indicted, discharged on AST, and length of stay (LOS). Results: After applying exclusion criteria, 395 total patients were included. Common AST used are PPI at 42% and Histamine-2 receptor antagonists (H2RAs) at 58%. We found that 56% of patients started on AST had no indication for SUP. At the time of downgrade from CCUs, AST was inappropriately continued on 74% of total patients. Subsequently, 20% were eventually discharged newly on AST. Of those newly discharged on AST, 67% were inappropriate. Longer LOS was associated with being newly discharged on inappropriate AST. The average LOS was 8.3 days for patients inappropriately discharged on new AST compared to 5.9 days for appropriate new AST (p=0.0284, Kruskal-Wallis test). Conclusion: While there have been studies on inappropriate use of AST among general medical patients, our study found that critically ill patients are equally affected by inappropriate AST use. This data supports that in critically ill patients, where morbidity and mortality are the highest, there is common misconceptions leading to inappropriate medication use. PPIs alone account for $13.6 billion in sales and is the 3rd largest class of drugs in the United States. The recognition of inappropriate AST use in critically ill patients can help significantly reduce healthcare expenditures and improve high value care.