Objective To evaluate intravenous proton-pump inhibitor (IV PPI) prescribing in a single academic teaching hospital. Methods A retrospective pilot study of 107 patients in a single United States military teaching hospital was conducted over a 1-month period. Clinical data were collected and analyzed for demographic features, prior medication use, admission hemoglobin level, service prescribing the IV PPI, indication for IV PPI, IV PPI treatment duration, gastroenterology consultant use, endoscopic findings, and blood products given. Indications for use were compared with current established guidelines to determine appropriate usage. Results A total of 683 doses of IV pantoprazole were prescribed over a 1-month period. Seventy-six patients (71%; 95% confidence interval [CI], 62–79%) who received IV PPIs did not meet the criteria for an appropriate indication for use. Ninety-nine patients in the study (93%; 95% CI, 86–96%) met criteria for an acceptable dosage given. The most common appropriate indication given was stress ulcer prophylaxis in a high-risk setting (13%; 95% CI, 8–21%) with appropriate use of this indication 45% of the time (95% CI, 29–62%). IV PPIs were appropriately prescribed most often by the medical intensive care unit (66.7%; 95% CI, 43–84%) and least often by the surgical wards services (16%; 95% CI, 7–33%). No discernable indication was given in 52% of cases (95% CI, 43–62%), and patients were not actually nil per os in 46% of these instances (95% CI, 34–59%). Conclusions Intravenous PPI prescribing habits in this military hospital facility are poor. A multifaceted approach including physician/pharmacist education, IV PPI ordering templates, and a consensus medical position statement from a major gastroenterological or prominent medical association may lead to more appropriate use.
Cost Intravenous Military Prescribing habits Proton-pump inhibitor
This is a preview of subscription content, log in to check access.
This study was performed without the financial support or sponsorship of any individual or institutional source.
Armstrong D. Intravenous proton pump inhibitor therapy: a rationale for use. Rev Gastroenterol Disord. 2005;5(suppl 2):S18–S30.PubMedGoogle Scholar
Therapeutic ASHP. Guidelines on stress ulcer prophylaxis: ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999;56:347–379.Google Scholar
Barkun A, Sabbah S, Enns R, et al. RUGBE Investigators: The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol. 2004;99(7):1247–1249. doi:10.1111/j.1572-0241.2004.30272.x.CrossRefGoogle Scholar
Barkun A, Bardou M, Marshall JK. Nonvariceal Upper GI Bleeding Consensus Conference Group: consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003;139(10):843–857.PubMedGoogle Scholar
Cook DJ, Griffith LE, Walter SD, et al. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care. 2001;5:368–375. doi:10.1186/cc1071.PubMedCrossRefGoogle Scholar
Daneshmend TK, Hawkey CJ, Langman MJ, Logan RF, Long RG, Walt RP. Omeprazole versus placebo for acute upper gastrointestinal bleeding: randomised double-blind controlled trial. BMJ. 1992;304(6820):143–147.PubMedCrossRefGoogle Scholar
Dorward S, Sreedharan A, Leontiadis GI, Howden CW, Moayyedi P, Forman D. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2006;(4):CD005415 (review).Google Scholar
Lin HJ, Lo WC, Lee FY, Perng CL, Tseng GY. A Prospective Randomized Comparative Trial Showing That Omeprazole Prevents Rebleeding in Patients With Bleeding Peptic Ulcer After Successful Endoscopic Therapy. Arch Intern Med. 1998;158:54–58. doi:10.1001/archinte.158.1.54.PubMedCrossRefGoogle Scholar
Enns R, Andrews CN, Fishman M, et al. Description of prescribing practices in patients with upper gastrointestinal bleeding receiving intravenous proton pump inhibitors: a multicentre evaluation. Can J Gastroenterol. 2004;18(9):567–571.PubMedGoogle Scholar
Guda NM, Noonan M, Kreiner MJ, Partington S, Vakil N. Use of intravenous proton pump inhibitors in community practice: an explanation for the shortage? Am J Gastroenterol. 2004;99(7):1233–1237.PubMedCrossRefGoogle Scholar
Afif W, Alsulaiman R, Martel M, Barkun AN. Predictors of inappropriate utilization of intravenous proton pump inhibitors. Aliment Pharmacol Ther. 2007;25(5):609–615.PubMedCrossRefGoogle Scholar
Rubison LL. The U.S. Military Health Service System and Socialized Medicine: A Contrast and Comparison. CA: Naval Postgraduate School Monterey; December 1995:1–78.Google Scholar
Johnson DA. Alternative dosing for PPI therapy: rationale and options. Rev Gastroenterol Disord. 2003;3(suppl 4):S10–S15.PubMedGoogle Scholar
White CM, Kalus JS, Quercia R, et al. Delivery of esomeprazole magnesium enteric-coated pellets through small caliber and standard nasogastric tubes and gastrostomy tubes in vitro. Am J Health Syst Pharm. 2002;59:2085–2088.PubMedGoogle Scholar
Barkun AN, Herba K, Adam V, Kennedy W, Fallone CA, Bardou M. High-dose intravenous proton pump inhibition following endoscopic therapy in the acute management of patients with bleeding peptic ulcers in the USA and Canada: a cost-effectiveness analysis. Aliment Pharmacol Ther. 2004;19(5):591–600. doi:10.1046/j.1365-2036.2004.01808.x.PubMedCrossRefGoogle Scholar
Lee KK, You JH, Wong IC, et al. Cost-effectiveness analysis of high-dose omeprazole infusion as adjuvant therapy to endoscopic treatment of bleeding peptic ulcer. Gastrointest Endosc. 2003;57(2):160–164. doi:10.1067/mge.2003.74.PubMedCrossRefGoogle Scholar
Laine L, Shah A, Bemanian S. Intragastric pH with oral vs. intravenous bolus plus Infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology. 2008;134(7):1836–1841.PubMedCrossRefGoogle Scholar