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GI prophylaxis - Should I order it or not -

GI prophylaxis - Should I order it or not -. Objective. 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. Which of followings require GI prophylaxis.

herman-collier
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GI prophylaxis - Should I order it or not -

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  1. GI prophylaxis- Should I order it or not -

  2. Objective • 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. Which of followings require GI prophylaxis • 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. • 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation. • 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. • 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation. • 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. • None of the above

  4. GI / Stress ulcer • 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

  5. Inappropriate use of GI prophylaxis • 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 Health-Syst Pharm. Vol 64 Jul 1, 2007.

  6. Economic effects • 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

  7. Potential side effects of PPI • 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. GI prophylaxis in ICU Major risk (need at least 1) 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) • 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)

  9. GI prophylaxis on wards • NONE !!!

  10. Which of followings require GI prophylaxis • 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. • 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation. • 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. • 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation. • 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. • None of the above

  11. Answer • 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. • 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation. • 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. • 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation. • 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. • None of the above

  12. Summary • 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. UCI pilot study • 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. Result * There were 5-7 patients who were placed on PPI as outpatient without indications

  15. Cost of Protonix (to UCI) Inpatient Outpatient 40mg PO = $0.05 /tab 20mg PO = < $0.05/tab • 40mg IV = $3.75/inj • 40mg PO = $0.22/tab • 20mg PO = $0.1/tab

  16. Result/Conclusion • 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. Future direction • 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

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