Digestive Diseases and Sciences

, Volume 54, Issue 9, pp 1947–1952 | Cite as

Use of Intravenous Proton-Pump Inhibitors in a Teaching Hospital Practice

  • Jacob G. Hoover
  • Annabel L. Schumaker
  • Kevin J. Franklin
Original Article


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 study was performed without the financial support or sponsorship of any individual or institutional source.


  1. 1.
    Armstrong D. Intravenous proton pump inhibitor therapy: a rationale for use. Rev Gastroenterol Disord. 2005;5(suppl 2):S18–S30.PubMedGoogle Scholar
  2. 2.
    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
  3. 3.
    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
  4. 4.
    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
  5. 5.
    Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994;330:377–381. doi: 10.1056/NEJM199402103300601.PubMedCrossRefGoogle Scholar
  6. 6.
    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
  7. 7.
    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
  8. 8.
    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
  9. 9.
    Kaplan GG, Bates D, McDonald D, Panaccione R, Romagnuolo J. Inappropriate use of intravenous pantoprazole: extent of the problem and successful solutions. Clin Gastroenterol Hepatol. 2005;3(12):1207–1214. doi: 10.1016/S1542-3565(05)00757-3.PubMedCrossRefGoogle Scholar
  10. 10.
    Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343:310–316. doi: 10.1056/NEJM200008033430501.PubMedCrossRefGoogle Scholar
  11. 11.
    Lew EA, Pisegna JR, Starr JA, et al. Intravenous pantoprazole rapidly controls gastric acid hypersecretion in patients with Zollinger-Ellison syndrome. Gastroenterology. 2000;118:696–704. doi: 10.1016/S0016-5085(00)70139-9.PubMedCrossRefGoogle Scholar
  12. 12.
    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
  13. 13.
    Pisegna JR. Pharmacology of acid suppression in the hospital setting: focus on proton pump inhibition. Crit Care Med. 2002;30(suppl 6):S356–S361. doi: 10.1097/00003246-200206001-00003.PubMedCrossRefGoogle Scholar
  14. 14.
    Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002;30(suppl 6):S362–S364. doi: 10.1097/00003246-200206001-00005.PubMedCrossRefGoogle Scholar
  15. 15.
    Tryba M, Cook D. Current guidelines on stress ulcer prophylaxis. Drugs. 1997;54:581–596.PubMedCrossRefGoogle Scholar
  16. 16.
    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
  17. 17.
    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
  18. 18.
    Slattery E, Theyventhiran R, Cullen G, et al. Intravenous proton pump inhibitor use in hospital practice. Eur J Gastroenterol Hepatol. 2007;19(6):461–464. doi: 10.1097/MEG.0b013e32810fd88a.PubMedCrossRefGoogle Scholar
  19. 19.
    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
  20. 20.
    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
  21. 21.
    Johnson DA. Alternative dosing for PPI therapy: rationale and options. Rev Gastroenterol Disord. 2003;3(suppl 4):S10–S15.PubMedGoogle Scholar
  22. 22.
    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
  23. 23.
    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
  24. 24.
    Erstad BL. Cost-effectiveness of proton pump inhibitor therapy for acute peptic ulcer-related bleeding. Crit Care Med. 2004;32(6):1277–1283. doi: 10.1097/01.CCM.0000127261.09066.6E.PubMedCrossRefGoogle Scholar
  25. 25.
    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
  26. 26.
    Tsoi KK, Lau JY, Sung JJ. Cost-effectiveness analysis of high-dose omeprazole infusion before endoscopy for patients with upper-GI bleeding. Gastrointest Endosc. 2008;67(7):1056–1063. doi: 10.1016/j.gie.2007.11.056.PubMedCrossRefGoogle Scholar
  27. 27.
    PayScale. Median Hourly Rate by Years Experience—Job: Registered Nurse (RN) (United States). Accessed November 10, 2007.
  28. 28.
    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

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Jacob G. Hoover
    • 1
  • Annabel L. Schumaker
    • 1
  • Kevin J. Franklin
    • 1
  1. 1.Department of Internal MedicineWilford Hall Medical CenterSan AntonioUSA

Personalised recommendations