Overuse Of Proton Pump Inhibitors Research Articles

PTU-001 Overuse Of Proton Pump Inhibitors And Strategies To Reduce Inappropriate Prescribing

IntroductionProton pump inhibitors (PPIs) are widely used but commonly over-prescribed.1 A range of adverse effects are associated with their use, including susceptibility to C. difficile infection, fractures, pneumonia and electrolyte...

Inappropriate use of proton pump inhibitors in a local setting.

There are growing concerns that the use of proton pump inhibitors (PPIs) may be inappropriate in instances that do not conform to evidence-based indications. This point-prevalence study aimed to investigate the frequency, indications and appropriateness of use of PPIs in hospitalised patients on a randomly chosen day. On a randomly chosen day, all inpatients were documented, and those on any form of PPIs on that day were determined. Indications for maintaining these patients on PPIs were obtained from the electronic medical records, which were then recorded and cross-referenced against a list of accepted indications adapted from the US Food and Drug Administration (FDA)-approved list. In all, 1,025 inpatients were documented. Of the 477 (46.5%) inpatients using PPIs, only 219 (45.9%) fulfilled the FDA-approved indications, while the majority (n = 258, 54.1%) did not. Overall, PPIs were not strictly indicated for use in 206 (43.2%) inpatients, according to FDA criteria. Of the 477 inpatients on PPIs, 52 (10.9%) had borderline indications based on expert consensus/guidelines other than FDA criteria. Although the use of PPIs is prevalent in hospitals, less than half of the hospitalised patients using PPIs in our study had evidence-based indications that supported such use. The overuse of PPIs has a negative impact on healthcare costs and may lead to adverse effects. Steps to curb the inappropriate use of PPIs should address factors such as indications for the initiation of PPIs, and reassessment of the need for ongoing PPI use in inpatients upon discharge and during outpatient reviews.

Indiscriminate Use of Inhibitors of the Proton Pump in the Mexican Population

Purpose: The aims of this study are to conduct a cohort study to determine whether Mexican population overuse of inhibitors of proton pump, to determine the use without indication, and also to identify alarm symptoms prior treatment. Methods: We collected three age groups, male and female gender, schooling, medication, who gave them the indication to use it, consumption habit, total consumption time, reason (dyspepsia, heartburn or regurgitation, indigestion, or only for medical reasons), and, if present, at least one alarm symptom prior to initiation of therapy. Results: A total of 136 random people were interviewed, of which 94 (69%) consumed PBI or ranitidine, the age group with the highest consumption was the 25-55 years in 75%, followed by 15% in those aged 55 years or older, and 10% in those aged 25 or younger. Women had more consumption by 62%. According to their schooling, predominated by 49% degree, 16% graduate, 12% primary school, 10% high school, none 10%, technical 3%. The most commonly used medication was omeprazole by 68% followed by 12% pantoprazole, 5% esomeprazole, and 3% lansoprazole; ranitidine by 12%. Forty percent of these were patent, 39% generic, 11% institutional, and 10% similar. Habit consumption was 78% corresponded to once daily, 19% twice per day, and 3% more than twice per day. Time consumption 41% more than 1 year, 21% for 6 months to 1 year, 21% for 1 month, 16% for 1 week, and 1% for 3 months. The most frequent symptom was dyspepsia by 68%, followed by heartburn and or regurgitation 14%, 14% had more than two symptoms, 2% indigestion, and 2% by medical indication. Seventeen percent had at least one alarm symptom prior treatment, of which 13% were dysphagia, 2% weight loss, 1% chest pain, and 1% hematemesis. The prescription was made by general practitioner in 37%, followed by gastroenterologist in 18%, 12% other specialist, 27% by friend, family member, or self-medication, and 6% by media. Conclusion: In the Mexican population, the overuse of proton pump inhibitors and ranitidine is of 70%, being used mostly by young patients under 55 years in which an average consumption is greater than 1 year. Omeprazole was the most used, frequency of self-medication was 33%, corresponding to a third of the cases, and 17% of people presented alarm symtoms prior treatment. The use of these medications should be better regulated, so as to have more precise indications, because many patients may have alarm symptoms and not be captured by health personnel indicated for monitoring and so avoid long-term complications.

Role of proton pump inhibitors in the occurrence and the prognosis of spontaneous bacterial peritonitis in cirrhotic patients with ascites

Proton pump inhibitors (PPIs) facilitate intestinal bacterial translocation. No robust data exist demonstrating that PPIs increase the risk of spontaneous bacterial peritonitis (SBP) and that PPIs worsen the prognosis of SBP patients. PPI use might be unsuitable for cirrhotic patients. To analyse: (i) the role of PPIs in the occurrence of SBP in cirrhotic patients; (ii) their impact on the prognosis of SBP patients; and (iii) the suitability of their use. In this retrospective case-control study, PPI use was first assessed in cirrhotic patients consecutively admitted with SBP (group I) and in a control group that included the same number of uninfected cirrhotic patients with ascites (group II). Afterwards, the impact of PPIs on SBP was assessed in group I by comparing survival of patients with and without PPIs. A total of 102 patients were included, 51 in each group. (i) SBP patients were more frequently treated by PPIs than controls (49 vs. 25%, P=0.014). (ii) In group I, patients with (n=25) and without (n=26) PPIs had similar survival rates at 1month (64.0±9.6% vs. 59.4±10.0%), 3months (41.2±10.2% vs. 44.6±10.6%), and 1year (26.6±9.6% vs. 28.9±10.1%), and similar median age at death (53 vs. 57years). (iii) The reason for PPI use was inappropriate or undocumented in 34% of group I and II. Proton pump inhibitors were more frequently used in SBP patients than in controls, but did not influence the prognosis in SBP. Overuse of PPIs was encountered in one-third of cirrhotic patients and should be avoided.

Histamine-2 receptor blockers vs proton pump inhibitors part 1: a literature review

While the use of histamine-2 receptor blockers (H2RBs) and proton pump inhibitors (PPIs) have been useful for the prophylaxis of peptic ulcer disease (PUD), there has been little information regarding which medication should be used initially. In the hospital setting, PPIs are often prescribed for PUD prophylaxis, even when patients have no history of gastroesophageal reflux disease. While PPIs have been demonstrated to be stronger than H2RBs, their long-term use can be detrimental to health-care outcomes. Owing to this overuse of PPIs, the use of H2RBs should be re-examined. In the first part of this two-part series on H2RBs vs PPIs, Ronnell Regidor will review several studies that assess the clinical scenarios in which H2RBs and PPIs should be used. Ultimately, this article proposes that, for patients without any gastrointestinal medical history, H2RBs should be the initial medication for PUD prophylaxis.

Sa1077 A Quality Improvement Project to Decrease the Overuse of Proton Pump Inhibitors in a University Medical Intensive Care Unit

Sa1077 A Quality Improvement Project to Decrease the Overuse of Proton Pump Inhibitors in a University Medical Intensive Care Unit

Inhibition of lysosomal enzyme activities by proton pump inhibitors

Proton pump inhibitors (PPIs) are pro-drugs requiring an acidic pH for activation. The specificity of PPI toward the proton pump is mainly due to the extremely low pH at the parietal cell canalicular membrane where the pump is located. Reactivity of PPIs was also observed in moderately acidic environments like the renal collecting duct. But no PPI effect on lysosomal enzymes has been observed possibly because the previous studies were performed with liver tissue, where PPIs are metabolized. The reactivity of PPIs (omeprazole, lansoprazole and pantoprazole) with a cysteine-containing peptide was analyzed by mass spectrometry, and the impact of PPIs on lysosomal enzymes was evaluated in cultured cells and mice. The effect of PPIs on the immune system was examined with a mouse tumor immunotherapy model. Incubation of a cysteine-containing peptide with PPIs at pH5 led to the conversion of most of the peptide into PPI-peptide adducts. Dose dependent inhibition of lysosomal enzyme activities by PPIs was observed in cultured cells and mouse spleen. Further, PPI counteracted the tumor immunotherapy in a mouse model. Our data support the hypothesis that many of the PPI adverse effects are caused by systematically compromised immunity, a result of PPI inhibition of the lysosomal enzymes. This novel mechanism complements the existing mechanisms in explaining the increased incidence of tumorigenesis and infectious diseases among PPI users and underlie the ongoing concern about the overuse of PPIs in adult and pediatric populations.

GRP-075 Gastroprotection with Non-Steroidal Anti-Inflammatory Drugs at Hospital Discharge: Do We Follow Local Guidelines?

BackgroundStudies have shown overuse of proton pump inhibitors (PPIs) that does not meet accepted criteria.Purpose The aim of this study was to determine the prevalence and appropriateness of gastroprotection with...

The Distressing Overuse of Gastric Acid Inhibitors

Gastric acid secretion by parietal cells is an energy consuming process that concentrates H? one million-fold. The energy required is produced by abundant mitochondria. High gastric acidity in combination with the proteolytic enzyme, pepsin, and the lipolytic enzyme, lipase, plays a key role in killing ingested microorganisms including bacteria [1, 2], viruses [3], and prions [4]. This corrosive juice can, however, overwhelm mucosal defense mechanisms leading to erosion and ulceration. Stress ulcers and less severe damage to the gastric mucosa may develop in critically ill patients. The damage, which occurs predominantly in the oxyntic mucosa, is thought to be caused by tissue hypoxia [5, 6]. Hypovolemic or hypotensive patients are at obvious risk of developing such ulcers, but severe illness also increases the risk of stress ulcers [7, 8], particularly in patients requiring mechanical ventilation. Experimental studies have suggested that antisecretory medications, e.g. proton pump inhibitors (PPIs) and histamine H2-receptor antagonists (H2RAs), reduce development of ulcers in the oxyntic mucosa by decreasing energy expenditure as well as raising intragastric pH [9, 10]. In this issue of Digestive Diseases and Sciences, Koczka et al. [11] report the overuse of stress ulcer prophylaxis in a large medical center. This adds to a large body of literature reporting the inappropriate overprescription of PPIs. Although the use of gastric acid inhibitors may reduce the risk of stress ulcers, it is important to target the therapy to patients at significant risk since PPIs have recently been associated with numerous adverse events, including infections. Gastric hypoacidity leads to bacterial overgrowth in the stomach and small intestine, in particular, an increase in gram negative and anaerobic bacteria [12, 13]. PPIs also increase the risk for Clostridium difficile infection (CDI) [14] and may predispose cirrhotic patients for spontaneous bacterial peritonitis [15, 16]. PPIs may also be associated with increased risk for respiratory infections, although the data are less clear [17, 18]. Nevertheless, in patients disposed to develop stress ulcers (that is patients with hypovolemia and/or hypoxia), it seems justified to prescribe prophylaxis with PPIs since the benefits of preventing a significant bleed in these very sick patients outweigh potential risks [19]. Critically ill patients probably profit from PPI stress ulcer prophylaxis, whereas in less ill patients with a minute risk of development of stress ulcers, the side effects may represent a greater risk for the patients than a possible small reduction in the risk of stress ulcer bleeding. In the present issue Koczka et al. [11] compared the attitude to stress ulcer prophylaxis between attending physicians and residents in a medical center in New York, reporting that half of the attending physicians thought that stress ulcer prophylaxis was indicated outside critical care settings. Perhaps even more problematic than short-term overuse of PPIs during the hospital stay is the fact that most of these patients are discharged on PPIs and thus probably remain on these drugs for prolonged periods without a proper indication [20, 21]. After patients are on PPIs for more than 3 months, stopping may be difficult due to rebound acid hypersecretion-induced dyspepsia [22, 23]. In conclusion, stress ulcer prophylaxis with PPIs is indicated in critically ill patients with hypovolemia and/or R. Fossmark H. Waldum (&) Department of Gastroenterology and Hepatology, St. Olavs Hospital, Prinsesse Kristinas Gate 1, 7006 Trondheim, Norway e-mail: helge.waldum@ntnu.no

An automated tool for detecting medication overuse based on the electronic health records

Medication overuse is a serious concern in healthcare as it leads to increased expenditures, side effects, and morbidities. Identifying overuse is only possible through excluding appropriate indications that are primarily mentioned in unstructured notes. We developed a framework for automatic identification of medication overuse and applied it to proton pump inhibitors (PPIs). We first created an indications knowledge base using data from drug labels, clinical guidelines, expert opinion, and other sources. We also obtained the list of current problems for 200 randomly selected inpatients who received PPIs using a natural language processing system and the discharge summaries of those patients. These problems were checked against the indications knowledge base to identify overuse candidates. Two gastroenterologists manually reviewed the notes and identified cases of overuse. Results from the automated framework were compared with the manual review. Reviewers had high interrater reliability in finding indications (agreement = 92.1%, Cohen's κ = 0.773). In 137 notes included in the final analysis, our system identified indications with a sensitivity of 74% (95%CI = 59-86) and specificity of 95% (95%CI = 87-98). In cases of appropriate use where the automated system also found one or more indications, it always included the correct indication. We created an automated system that can identify established indications of medication use in electronic health records with high accuracy. It can provide clinical decision support for identifying potential overuse of PPIs and could be useful for reducing overuse and encouraging better documentation of indications.

Sa1158 Overuse of Proton Pump Inhibitors in a University Medical Intensive Care Unit

Sa1158 Overuse of Proton Pump Inhibitors in a University Medical Intensive Care Unit

Sa1159 Venous Blood Gas Calculated Hematocrit is an Accurate Predictor of Hematocrit in Patients With Acute Upper Gastrointestinal Hemorrhage

Background: Proton pump inhibitors (PPI) are a commonly used medication in the medical intensive care unit (MICU). Overuse of PPIs can lead to increased healthcare costs as well as a possible risk of Clostridium difficile infection and aspiration pneumonia. The aim of our study is to analyze the prescribing patterns of PPIs in the MICU in order to identify opportunities for improvement. Materials and Methods: 507 MICU admissions were retrospectively reviewed for data concerning PPI use. PPI prescriptions and their indications were analyzed. Results: Of 507 MICU admissions reviewed, 342 (67.5 %) received a PPI. Of the 342 who received a PPI, 40 patients (11.7%) had no documented indication. In addition, 78 admissions out of the 342 (22.8%) received PPI solely for stress ulcer prophylaxis, where an H-2 blocker would have sufficed. Discussion: Our study revealed that PPIs were frequently prescribed in our MICU, but that up to one third (34.5%) of the prescriptions were inappropriate, and represent opportunities for cost savings and possibly reduced clinical complications. Our next step is to improve the rate of appropriate PPI prescription in our ICU through a combination of educational modules and direct interventions to the availability of the drug in current pharmacy order sets.

STOPP and START screening tools as supplements to the pharmaceutical medicines review

BackgroundInappropriate prescribing is a well-documented problem in older people. The screening tools STOPP (Screening Tool of Older Peoples' Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) have...

Stress ulcer prophylaxis in non‐critically ill patients: a prospective evaluation of current practice in a general surgery department

There is little evidence regarding the benefit of stress ulcer prophylaxis (SUP) outside a critical care setting. Overprescription of SUP is not devoid of risks. This prospective study aimed to evaluate the use of proton pump inhibitors (PPIs) for SUP in a general surgery department. Data collection was performed prospectively during an 8-week period on patients hospitalized in a general surgery department (58 beds) by pharmacists. Patients with a PPI prescription for the treatment of ulcers, gastro-oesophageal reflux disease, oesophagitis or epigastric pain were excluded. Patients admitted twice during the study period were not reincluded. The American Society of Health-System Pharmacists guidelines on SUP were used to assess the appropriateness of de novo PPI prescriptions. Among 255 patients in the study, 138 (54%) received a prophylaxis with PPI, of which 86 (62%) were de novo PPI prescriptions. A total of 129 patients (94%) received esomeprazole (according to the hospital drug policy). The most frequent dosage was at 40 mg once daily. Use of PPI for SUP was evaluated in 67 patients. A total of 53 patients (79%) had no risk factors for SUP. Twelve and two patients had one or two risk factors, respectively. At discharge, PPI prophylaxis was continued in 33% of patients with a de novo PPI prescription. This study highlights the overuse of PPIs in non-intensive care unit patients and the inappropriate continuation of PPI prescriptions at discharge. Treatment recommendations for SUP are needed to restrict PPI use for justified indications.

Balancing the Risks and Benefits of Proton Pump Inhibitors

Balancing the Risks and Benefits of Proton Pump Inhibitors

Patterns and Predictors of Proton Pump Inhibitor Overuse among Academic and Non-Academic Hospitalists

In the hospital setting, several studies have reported proton pump inhibitor (PPI) overuse, a majority of which is continued after discharge. In addition to being expensive, PPIs are associated with an increased risk of infections, osteoporosis and serious drug interactions. We examined the trends and predictors of PPI guidelines non-compliance among academic and non-academic hospitalists in USA. Oral PPI prescriptions initiated by 2 academic and 2 non-academic hospitalist groups were reviewed. Prescription indications were recorded when explicitly stated in the chart. Otherwise, qualified physicians reviewed the chart to make such determination. Indications were then compared to the published guidelines. Several variables were tested to determine independent predictors of initiation and post discharge continuation of guideline non-compliant prescriptions. Of the 400 PPI prescriptions 39% were guideline compliant. Academic hospitalists were significantly more compliant with PPI prescription guidelines (50 vs 29%). Gastrointestinal ulcer bleeding prophylaxis (GIP) for low risk patients was the most common indication for non-compliant prescriptions, while that of guideline compliant prescriptions was dyspepsia treatment. Independent predictors of the initiation of guideline non-compliant prescriptions were non-academic hospitalist group, PPI indication not documented in the chart, and GIP as part of the admission orderset. The latter was an independent predictor of those prescriptions continuation post-discharge (protective) in addition to non-academic hospitalists group. Hospitalists overprescribe PPI to a level comparable to that of the non-hospitalist providers in the literature. Understanding the determinants of increased compliance among academic groups is instrumental to design interventions aimed at increasing PPI prescription compliance.

Microscopic Colitis Associated with Omeprazole and Esomeprazole; Overuse of Proton Pump Inhibitors; Chest Pain in a Young Man Treated with Prazosin; Mirtazapine-Associated Hyponatremia; Nephrotoxicity Associated with Intravenous Colistin; Drug-Induced Parkinsonism: A Review

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Answers linked to Cunningham R, Dial S. Is over-use of proton pump inhibitors [PPIs] fuelling the current epidemic of Clostridium difficile-associated diarrhoea [CDAD]? J Hosp Infect 2008; 70:1–6.

Answers linked to Cunningham R, Dial S. Is over-use of proton pump inhibitors [PPIs] fuelling the current epidemic of Clostridium difficile-associated diarrhoea [CDAD]? J Hosp Infect 2008; 70:1–6.

Questions linked to Cunningham R, Dial S. Is over-use of proton pump inhibitors [PPIs] fuelling the current epidemic of Clostridium difficile-associated diarrhoea [CDAD]? J Hosp Infect 2008;70:1–6.

Questions linked to Cunningham R, Dial S. Is over-use of proton pump inhibitors [PPIs] fuelling the current epidemic of Clostridium difficile-associated diarrhoea [CDAD]? J Hosp Infect 2008;70:1–6.

Overuse of proton pump inhibitors

Background: There have been concerns raised about the potential adverse effects of proton pump inhibitors, especially with long-term use. In particular, their potent action can suppress the features and delay the diagnosis of gastric cancer, while prolonged exposure may hasten the development of gastric carcinoids. Aim: To examine the use of proton pump inhibitors in patients at the major teaching hospital in Tasmania, Australia, principally to determine the appropriateness of the therapy according to published guidelines. Methods: A retrospective review of the medical records of all patients prescribed any of the proton pump inhibitors at the hospital over a 7-month period, was performed. An extensive range of demographic and clinical variables was recorded for each patient. The patients were also asked a series of questions during their hospitalization to extract some of the relevant information – in particular, if and when they had undergone endoscopy. Results: The 200 patients (52% males) had a mean age of 69 ± 16·4 years. The most common indications for using proton pump inhibitors were acute gastrointestinal bleeding (20·9%), severe refractory ulcerating oesophagitis (17·3%), mild/moderate oesophageal reflux (17·3%) and refractory peptic ulcer (11·7%). A large number of patients were using a proton pump inhibitor for ‘other’ indications (39·6%). The prescribing of proton pump inhibitors satisfied the approved indications, as outlined in the Australian Schedule of Pharmaceutical Benefits, in only 37·1% of cases. Endoscopy had been performed in 54·1% of patients prior to commencing therapy with a proton pump inhibitor and within the next 7 days in another 12·8% of patients. Only 59% of patients had previously been treated with an H2-receptor antagonist before commencing therapy with a proton pump inhibitor. Even worse, only 58·5% of patients had used an H2-receptor antagonist before a proton pump inhibitor for mild/moderate oesophagitis. The median duration of proton pump inhibitor therapy for patients admitted to the hospital and already receiving one of the drugs was 450 days. Over half of the patients were being concurrently treated with other drugs which are known to cause or exacerbate gastro-oesophageal disease, and 18% were smokers. Conclusions: Whereas the proton pump inhibitors are undoubtedly effective agents, studies of their prescribing in practice consistently suggest over-use prior to endoscopy, use in patients who do not fit the approved criteria, and prescribing for indications in which ‘less powerful’ agents should have been sufficiently effective for the patient’s symptoms. This poses economic and safety concerns, particularly in light of the suggestion that these drugs could delay the diagnosis of gastric cancer.