Overuse of acid suppressive therapy in hospitalised patients with pulmonary diseases

Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients

Background

Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences.

Objective

To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST.

Methods

This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified.

Results

During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007).

Conclusion

This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.

Prescribing habits for the use of omeprazole as a gastroprotectant in dogs in a veterinary teaching hospital

OBJECTIVES

To examine the prescribing habits for omeprazole in a veterinary teaching hospital and to evaluate the effect of a clinical audit on omeprazole prescription.

MATERIAL AND METHODS

Observational study with retrospective clinical audit followed by a prospective study. The evaluated data about omeprazole prescription included the dose, frequency and indication. These were assessed according to published guidelines. A seminar about the audit and current guidelines on the use of omeprazole was organised for all members of clinical staff. Prospective data collection was conducted after the seminar. A comparison of the collected data before and after the clinical audit was made.

RESULTS

A total of 301 dogs were prescribed omeprazole in the veterinary teaching hospital during the study period (including the retrospective and prospective parts). Complete data were acquired from 240 patients. The prescribed frequency of omeprazole was inappropriate in 23 (16.5%) of the prescriptions in the retrospective section but in only five (5.0%) in the prospective study. Inappropriate indications were reported in 12 (8.6%) patients in the retrospective section and in two patients (2.0%) in the prospective study. Overall inappropriate omeprazole prescription was identified in 34 (24.5%) patients in the retrospective part and in seven (6.9%) patients in the prospective part. There was a statistically significant difference between the two groups in frequency, indication and overall prescription of omeprazole.

CLINICAL SIGNIFICANCE

This study details the frequency of inappropriate prescription of omeprazole in a veterinary teaching hospital and provides some evidence that dissemination of guidelines based on clinical audit can improve prescribing habits.

[Proton-pump inhibitors treatment. Does your patient really need it?]

INTRODUCTION

Proton-pump inhibitors (PPI) are frequently prescribed for wide gastrointestinal disorders. The indications are well established, although a high rate of misuse has been reported.

METHODS

Observation cross-sectional study conducted a tertiary hospital. Adult patients who attended the emergency department were eligible. The appropriate indication was evaluated. Also, the prescription period, dosage and the prescribing clinician were reviewed.

RESULTS

300 patients were included. The indication was adequate in 142 patients (47.3%). The main indication was the primary prophylaxis for NSAIDs/ASA-induced enteropathy (n=95 patients, 31.7%). Polypharmacy was the main misuse indication (n=82 patients, 27.3%). The median prescription duration was 31 months (IQR 9-72), ranging from one month to 360 months. The duration was lower in those with correct indication (42.3 vs 59.6 months, P=.02). The primary care physician was the main responsible for prescription (n=165 patients, 55%), followed by gastroenterologist (n=38 patients, 12.7%) without significant differences in appropriateness by speciality.

CONCLUSIONS

Studies like this raise awareness about the PPI overuse and misuse. Deprescribing should be considered as essential to reduce iatrogenic risk and redundant health expenditure.

Controversial link between proton pump inhibitors and anticancer agents: review of the literature

Drug-drug interactions represent a topic of great interest, not only due to the risk of unexpected adverse events but also due to the possibility of altering the effectiveness of a specific treatment. Inappropriate or concomitant use of drugs can often lead to changes in the bioavailability of various compounds, resulting in pharmacokinetic alterations. A recent example is the concomitant administration of proton pump inhibitors (PPIs) and anticancer agents. PPIs are overused beyond their classic indications, resulting in a high risk of interactions with other drugs, such as anticancer agents, both PO and intravenous. However, the real clinical impact of concomitant acid suppression therapy and anticancer therapies remains controversial and is not yet fully understood. Certainly, the gut microbiota plays a key role in regulating the response of the immune system, and PPIs can significantly alter the gut microbiome, resulting in gut dysbiosis. Indeed, while the link sometimes appears to lead to negative outcomes, as in the case of immunotherapy, oral capecitabine, or tyrosine kinase inhibitors, in other cases, it seems to enhance the effectiveness of intravenous chemotherapy. In this review, I analyse the possible drug interactions between PPIs and the main classes of anticancer drugs.

Inappropriate Prescribing of Proton Pump Inhibitors in Outpatient Clinics

Proton pump inhibitors are the commonly prescribed drugs for acid-related disorders. However, many of those prescriptions are inappropriate in inpatient and outpatient settings according to the recommended guidelines. Many studies have been conducted in inpatient clinics, but data about the appropriateness of proton pump inhibitor prescribing in outpatient clinics are scarce. Therefore, the aim of this study was to determine inappropriate proton pump inhibitor prescribing rates among patients admitted to a tertiary hospital family medicine outpatient clinic. A total of 259 patients (median age = 59 years; 72.6% women) were enrolled into the study and 35.9% of them had no proper indications to utilize proton pump inhibitors. Inappropriate proton pump inhibitor usage rate was significantly higher in patients older than 60 years compared with their younger counterparts (62.4% vs. 37.6%; p = .001). The most frequent reason to use a proton pump inhibitor with nonapproved indications was polypharmacy (41.9%). Despite endoscopic evaluation, 41.9% of the patients received a proton pump inhibitor without an approved indication. A significant proportion of nonindicated prescriptions were a consequence of continued prescribing without re-evaluating patients in outpatient clinics. Consideration of proton pump inhibitor indications according to the guidelines in every admission may prevent inappropriate prescriptions.

The appropriate use of proton pump inhibitors (PPIs): Need for a reappraisal

The advent of powerful acid-suppressive drugs, such as proton pump inhibitors (PPIs), has revolutionized the management of acid-related diseases and has minimized the role of surgery. The major and universally recognized indications for their use are represented by treatment of gastro-esophageal reflux disease, eradication of Helicobacter pylori infection in combination with antibiotics, therapy of H. pylori-negative peptic ulcers, healing and prophylaxis of non-steroidal anti-inflammatory drug-associated gastric ulcers and control of several acid hypersecretory conditions. However, in the last decade, we have witnessed an almost continuous growth of their use and this phenomenon cannot be only explained by the simple substitution of the previous H2-receptor antagonists, but also by an inappropriate prescription of these drugs. This endless increase of PPI utilization has created an important problem for many regulatory authorities in terms of increased costs and greater potential risk of adverse events. The main reasons for this overuse of PPIs are the prevention of gastro-duodenal ulcers in low-risk patients or the stress ulcer prophylaxis in non-intensive care units, steroid therapy alone, anticoagulant treatment without risk factors for gastro-duodenal injury, the overtreatment of functional dyspepsia and a wrong diagnosis of acid-related disorder. The cost for this inappropriate use of PPIs has become alarming and requires to be controlled. We believe that gastroenterologists together with the scientific societies and the regulatory authorities should plan educational initiatives to guide both primary care physicians and specialists to the correct use of PPIs in their daily clinical practice, according to the worldwide published guidelines.

Imprudent Gastro-protective Approach in Majority of Specialists' Clinics of a Tertiary Hospital

INTRODUCTION

One out of four prescriptions in out-patient departments contains a gastro-protective drug (APUD) - PPI/ H2 Blockers/ Antacids/ Ulcer Protective's. These drugs should be prescribed only when there is a justified indication. To assess the prescriptions of gastro-protective agents for appropriateness and rationality, in a tertiary care hospital setup.

MATERIALS AND METHODS

It was a cross-sectional observational study conducted from Aug 2013 to Dec 2013 at OPDs of a Tertiary Care Teaching Hospital, Pune. A total of 260 prescriptions containing gastro-protective agents were analysed for appropriateness and rationality. Rationality of drug use was assessed by referring to standard textbooks and guidelines. Cost difference data was analysed by Wilcoxon signed rank test using GraphPad Prism 6.

RESULTS

Most common class of gastro-protective agents was Proton pump inhibitors (PPIs)-73.77% (Pantoprazole & Dexrabeprazole). Only 37.3% prescriptions had an adequate indication for these drugs {GI prophylaxis (29.6%) and Acid Peptic Disease treatment (7.7%)}. Two irrational Fixed dose combinations found in the study were PPI with prokinetic agent (n=65) and Proton Pump Inhibitor + NSAID combination (n=2). Formulation, spelling and strength errors were found with 75 prescribed drugs. Medication instructions were lacking with most of the drugs. Drug interactions with co-prescribed drugs could be anticipated in 79 cases. Injudicious use of anti-peptic ulcer agents significantly increased the cost of prescriptions (p<0.0001).

CONCLUSION

Anti-ulcer drugs are overenthusiastically prescribed by all specialties which can predispose to adverse effects, drug interactions, increased cost and even erroneous prescriptions.

Multimorbidities and Overprescription of Proton Pump Inhibitors in Older Patients

OBJECTIVES

To determine whether there is an association between overprescription of proton pump inhibitors (PPIs) and multimorbidities in older patients.

DESIGN

Multicenter prospective study.

SETTING

Acute geriatric medicine at the University Hospital of Nantes and the Hospital of Saint-Nazaire.

PARTICIPANTS

Older patients aged 75 and over hospitalized in acute geriatric medicine.

MEASUREMENTS

Older patients in acute geriatric medicine who received proton pump inhibitors. Variables studied were individual multimorbidities, the burden of multimorbidity evaluated by the Cumulative Illness Rating Scale, age, sex, type of residence (living in nursing home or not), functional abilities (Lawton and Katz scales), nutritional status (Body Mass Index), and the type of concomitant medications (antiaggregant, corticosteroids', or anticoagulants).

RESULTS

Overprescription of proton pump inhibitors was found in 73.9% older patients. In the full model, cardiac diseases (odds ratio [OR] = 4.17, p = 0.010), metabolic diseases (OR = 2.14, p = 0.042) and corticosteroids (OR = 5.39, p = 0.028) were significantly associated with overprescription of proton pump inhibitors. Esogastric diseases (OR = 0.49, p = 0.033) were negatively associated with overprescription of proton pump inhibitors.

CONCLUSION

Cardiac diseases and metabolic diseases were significantly associated with overprescription of proton pump inhibitors.

Association between proton pump inhibitor therapy and clostridium difficile infection: a contemporary systematic review and meta-analysis

Introduction

Emerging epidemiological evidence suggests that proton pump inhibitor (PPI) acid-suppression therapy is associated with an increased risk of Clostridium difficile infection (CDI).

Methods

Ovid MEDLINE, EMBASE, ISI Web of Science, and Scopus were searched from 1990 to January 2012 for analytical studies that reported an adjusted effect estimate of the association between PPI use and CDI. We performed random-effect meta-analyses. We used the GRADE framework to interpret the findings.

Results

We identified 47 eligible citations (37 case-control and 14 cohort studies) with corresponding 51 effect estimates. The pooled OR was 1.65, 95% CI (1.47, 1.85), I² = 89.9%, with evidence of publication bias suggested by a contour funnel plot. A novel regression based method was used to adjust for publication bias and resulted in an adjusted pooled OR of 1.51 (95% CI, 1.26–1.83). In a speculative analysis that assumes that this association is based on causality, and based on published baseline CDI incidence, the risk of CDI would be very low in the general population taking PPIs with an estimated NNH of 3925 at 1 year.

Conclusions

In this rigorously conducted systemic review and meta-analysis, we found very low quality evidence (GRADE class) for an association between PPI use and CDI that does not support a cause-effect relationship.

Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care

Background:  Inappropriate prescriptions of proton pump inhibitors (PPI) in hospital and primary care have been widely reported. Recommendations from hospital have been implicated as one reason for inappropriate prescriptions of PPI in primary care. Objective:  To quantify the amount of appropriate PPI recommendations in hospital discharge letters and the influence of these recommendations on general practitioners' (GPs') PPI-prescriptions. Materials and Methods:  This is an observational study in 31 primary care practices. We identified patients discharged from hospital with PPI recommendation between 2006 and 2007 and assessed practice records and PPI prescription six months prior and after hospital admission. Hospital recommendation for continuous PPI-treatment and continuation by GPs was classified as appropriate, inappropriate or uncertain. Logistic regression analysis was used to calculate factors associated with indicated and non-indicated PPI continuation. Results:  In 263 (58%) out of 506 patients discharged from 35 hospitals with a PPI recommendation no indication could be found. Non-indicated PPIs were continued by GPs in 58% for at least 1 month. Indicated PPIs were discontinued in 33%. Two thirds of non-indicated PPIs were initiated in hospital. The strongest factor associated with non-indicated continuation was a PPI-prescription prior to hospital admission [OR: 3.0; 95% confidence interval (CI): 1.7-5.4]. This was also the strongest factor for continuation of an indicated PPI medication (OR: 3.2; 95% CI: 1.4-7.5). Conclusions:  We found a strong influence of hospital recommendations and previous prescriptions on PPI prescriptions after discharge. Hospitals should critically review their practice of recommending PPI and document indications. GPs should carefully assess hospital recommendations and their medication prior to admission to avoid over- and under-prescribing.

Appropriateness of treatment recommendations for PPI in hospital discharge letters

Purpose

The reasons for the dramatic increase in proton pump inhibitors (PPI) prescriptions remain unclear and cannot be explained solely by increased morbidity, new indications or a decrease in alternative medication. Inappropriate use and discharge recommendations in hospitals are considered to be possible explanations. As the quality of PPI recommendations in hospital discharge letters in Germany has not been investigated to date, we have studied the appropriateness of these referrals.

Methods

Hospital discharge letters with recommendations for PPI medication from 35 primary care practices in the county of Mecklenburg-Western Pomerania (MV; North-east Germany) were collected and analysed, and the appropriateness of the PPI indication was rated.

Results

No information justifying the recommendation for continuous PPI medication could be identified in 54.5% of the discharge letters; in 12.7%, the indication was uncertain, and in 32.7%, we found an evidence-based indication for PPI medication. The most common indication for adequate PPI use was nonsteroidal anti-inflammatory drug-prophylaxis in high-risk patients.

Conclusions

Inadequate recommendations for PPIs in discharge letters are frequent. This may lead to a continuation of this therapy in primary care, thereby unnecessarily increasing polypharmacy and the risk of adverse events as well as burdening the public health budget. Hospitals should therefore critically review recommendations for PPI medication and the dosage thereof in their discharge letters and clearly document the reason for PPI use and the need for continuous prescription in primary care.

Dyspeptic symptom development after discontinuation of a proton pump inhibitor: a double-blind placebo-controlled trial

OBJECTIVES

Conflicting data exist on whether discontinuation of proton pump inhibitors (PPIs) is associated with rebound secretion of gastric acid.

METHODS

A total of 48 healthy Helicobacter pylori-negative volunteers (24 females) were randomized in a double-blinded manner to treatment with either pantoprazole 40 mg or placebo once daily for 28 days. Dyspeptic symptoms were registered daily using the Glasgow dyspepsia score (GDS) 2 weeks before, during, and 6 weeks after treatment. Plasma levels of gastrin and serum levels of chromogranin-A levels were measured before, during, and after treatment.

RESULTS

During the 2 weeks before treatment, the placebo group had a mean GDS of 0.20 + or - 0.7 compared with the pantoprazole group score of 0.54 + or - 1.3 (NS). No significant differences between the symptom severity scores of the two groups were shown during the treatment period. During the first week after discontinuation of treatment, the pantoprazole group had a mean symptom score of 5.7 + or - 11.7 vs. 0.74 + or - 2.6 in the placebo group (P<0.01). A total of 11 out of 25 (44%) subjects in the pantoprazole group developed dyspepsia compared with 2 out of 23 (9%) in the placebo group (P<0.01). During the second week of follow-up, the pantoprazole group had a mean symptom score of 1.6 + or - 3.4 compared with 0 + or - 0 in the placebo group (P<0.05). There were no significant differences in the mean symptom score for the pantoprazole group (1.1 + or - 0.6) compared with the placebo group (0.4 + or - 0.3) during the third week of follow-up. Symptom scores during the first week after treatment correlated with basal (P<0.01) and meal-stimulated (P<0.01) gastrin levels at the end of treatment.

CONCLUSIONS

A 4-week course of pantoprazole seems to induce dyspeptic symptoms in previously asymptomatic healthy H. pylori-negative subjects. The correlation between symptom score and gastrin levels suggests that these symptoms are due to acid rebound hypersecretion and seem to be related to the degree of acid inhibition.

Impact of dialysis on gastroesophageal reflux, dyspepsia, and proton pump inhibitor treatment in patients with chronic renal failure

BACKGROUND/AIMS

Gastrointestinal (GI) symptoms are common in patients with chronic renal failure. Patients with chronic renal failure on dialysis have a high consumption of proton pump inhibitors (PPIs) and long-term treatment is very common. The aim of the study was to investigate the prevalence of gastroesophageal reflux symptoms (GORS), dyspeptic symptoms, and PPI treatment in patients with chronic renal failure on dialysis and to compare the impact of the different types of dialysis on these upper GI symptoms and PPI treatment.

METHODS

One hundred and twelve peritoneal dialysis (PD) patients and 157 hemodialysis (HD) patients participated in the study. The patients were asked to complete two questionnaires: Gastrointestinal Symptom Rating Scale measuring GI symptoms in general and a GI symptom questionnaire evaluating upper GI tract symptoms specifically. Information about the use of and indication for PPI treatment and onset of GI symptoms was obtained by interviewing the patients and/or reviewing the medical records.

RESULTS

Dyspepsia was more common among PD patients compared with HD patients (55 vs. 38%, P=0.003). The start of dialysis tended to have a greater impact on dyspepsia (P=0.09) and GORS (P=0.09) in PD patients than in HD patients. The proportion of patients who started PPI treatment after onset of dialysis was high but did not differ between PD and HD patients (51 vs. 44%, P=0.43). A higher proportion of women with chronic renal failure started PPI treatment after the onset of dialysis than men with chronic renal failure (P=0.002).

CONCLUSION

Dyspepsia and GORS leading to PPI treatment are common in CRF patients on dialysis. Dialysis in general and the type of dialysis seem to affect the presence of upper GI symptoms.

Discrepancies between home medications listed at hospital admission and reported medical conditions

BACKGROUND

One of the Joint Commission on Accreditation of Healthcare Organization's National Patient Safety Goals is for hospitals to accurately and completely reconcile patients' medications. Unfortunately, medication histories in charts might bc inaccurate and incomplete. In a thorough medication history, each medication should match a particular reported medical condition. The use of medications without a clear reported indication is of particular concern and has been associated with inappropriate use and polypharmacy.

OBJECTIVES

The purposes of this study were to evaluate the occurrence of discrepancies between home medications listed in hospital admission notes and patients' reported medical conditions and to describe the types of medications most often identified as not having a corresponding indication.

METHODS

In this retrospective observational study, data were included from adult patients (> or =18 years of age) who were receiving > or =3 home medications on admission to medical wards at a university hospital during a 6-month period. Each home medication listed in the admission note, together with any preadmission paperwork, was matched with an indication listed in the note. Medications were deemed unspecified if an indicated disease state or condition for the medication was not reported.

RESULTS

Data from 121 patients were included. The majority (91.7%) of the patients were admitted to an internal medicine service. Eighty-four patients (69.4%) had > or =1 unspecified medication listed in the admission note. Patients with > or =1 unspecified home medication reported taking a significantly higher number of home medications (10.2 [4.5] vs 7.5 [3.5] in those without unspecified medications; P = 0.007). Thirty-two patients (26.4%) were receiving proton pump inhibitors or histamine type 2 antagonists without a reported indication. Seventeen patients (14.0%) were receiving selective serotonin reuptake inhibitors without a reported indication.

CONCLUSIONS

Nearly 70% of patients admitted to a medical ward had > or =1 unspecified medication listed in the admission note. Based on these results, health care professionals must bc careful to obtain and document complete medication histories with matching indications.

Inadequate use of proton-pump inhibitors in patients with liver cirrhosis

OBJECTIVES

Patients with liver cirrhosis have a high prevalence of gastrointestinal symptoms. The use of antiacid therapy (AAT) in these patients is unexplored. We aimed to assess the use of AAT in cirrhotic patients.

METHODS

A total of 128 consecutive cirrhotic patients were evaluated for the use of and indications for acid-suppressive agents. Upper endoscopy findings and concomitant medications were registered. A validated questionnaire was used to measure the gastrointestinal symptom burden. Adequate indications for AAT were those strongly supported by the medical literature.

RESULTS

Forty percent (n=51) of patients with cirrhosis were on AAT. Thirty-seven percent (n=19) of these had adequate and 63% (n=32) inadequate indications for AAT. The major inadequate indication was previous variceal bleeding (34%). Patients with inadequate indications for AAT had increased severity of symptoms of indigestion compared with patients without AAT (P<0.05). Multivariate analysis revealed that inadequate use of AAT was independently related only to previous variceal bleeding and the number of concomitant medications.

CONCLUSION

AAT is used by a large proportion of patients with cirrhosis. In the majority, therapy is based on inadequate indications, mainly continuous long-term therapy after previous variceal bleeding. Patients with an inadequate indication for acid-suppressive medications have increased severity of symptoms of indigestion, indicating that gastrointestinal symptoms might be a factor contributing to proton-pump inhibitor consumption in these patients.

Prevalence of gastrointestinal symptoms in patients with chronic obstructive pulmonary disease

BACKGROUND

Symptoms of gastro-oesophageal reflux disease (GERD) have previously been shown to be of importance in patients with asthma. Limited data, however, exist on the prevalence of GERD in patients with chronic obstructive pulmonary disease (COPD), and information about the occurrence of the total burden of gastrointestinal (GI) symptoms in these patients is lacking.

METHODS

A total of 113 patients with COPD completed four self-administered questionnaires: the Gastrointestinal Symptom-Rating Scale (GSRS), ROME II modular questionnaires (criteria for irritable bowel syndrome), the Psychological General Well-Being index (PGWB), and the Hospital Anxiety and Depression scale. Eighty-two patients with chronic renal failure (CRF) and 2000 healthy individuals from the general Swedish population served as controls.

RESULTS

The total GSRS score in patients with COPD was 2.12 (1.92-2.28) which was significantly higher than the score from the general population of 1.96 (1.81-2.12). No significant difference between COPD and CRF patients was, however, observed, in any of the GSRS dimensions. Patients in the COPD group had lower total PGWB scores compared both with CRF patients 90 (78-104) vs. 98 (83-113) (P<0.05) and with the general population 103 (102-104) (P<0.001). A negative correlation between the GSRS and PGWB scores (r=-0.49; P<0.001) was observed in patients with COPD. Sixteen (14%) of the patients with COPD fulfilled the Rome II criteria for irritable bowel syndrome.

CONCLUSION

The prevalence of GI symptoms is higher in patients with COPD than in healthy individuals, but not higher than in CRF patients. The GI symptoms are associated with impairments in psychological well-being, and they require diagnostic workups to explore different treatment options in these patients.

Stress ulcer prophylaxis in hospitalized patients not in intensive care units

PURPOSE

A review is presented of the evidence behind the current use of therapies for the prevention of stress-related mucosal disease and bleeding in the nonintensive care unit (ICU), general medicine population.

SUMMARY

The use of proton pump inhibitors and histamine H2-receptor antagonists for the prevention of stress ulcers has been well-defined in critical care patients. In 1999, the American Society of Health-System Pharmacists (ASHP) published guidelines on the use of stress ulcer prophylaxis in medical, surgical, respiratory, and pediatric ICU patients. In recent years, the practice of stress ulcer prophylaxis has become increasingly more common in general medicine patients, with little to no evidence to support it. Multiple risk factors have been identified for the development of stress ulcers, such as major trauma, severe head injury, multiple organ failure, burns covering more than 25-30% of the body, and major surgical procedures. Multiple studies have demonstrated the overuse of acid-suppressive therapy (AST), with as many as 71% of patients admitted to the hospital receiving some form of treatment. While many practitioners view AST to be harmless, its use is not without risks. Subsequently, a significant number of patients are discharged home on these medications, increasing economic cost and potentially increasing the risk of pneumonia or Clostridium difficile-associated disease.

CONCLUSION

AST is commonly misused in hospitals, with as many as 71% of patients in general medicine wards receiving some sort of AST without an appropriate indication. Anticoagulant therapy has been identified as a risk factor for GI bleeding in hospitalized patients, but prophylaxis with AST has not been found to lower that risk. Although PPIs, H2-antagonists, and antacids are often viewed as safe, patients--particularly those with complicated disease states and complex drug regimens--should not be unduly exposed to the adverse effects and drug interactions associated with those agents. Many such patients treated with the drugs while hospitalized continue to receive AST as outpatients. The cost of inappropriate stress ulcer prophylaxis in medicine patients was found in one trial to exceed $111,000 for one year. The use of AST for the prevention of stress ulcers in general medicine patients is currently not recommended or supported in the clinical literature.

Acid and non-acid gastro-esophageal refluxes in children with chronic pulmonary diseases

OBJECTIVES

Acid gastro-esophageal reflux has been shown associated with chronic pulmonary diseases. The role of non-acid refluxes in these children is still unknown. Therefore we investigated the prevalence of acid and non-acid refluxes, and their association with desaturations, in children with chronic pulmonary symptoms.

METHODS

In 25 children aged 6 months to 15 years with unexplained chronic cough, wheeze or sputum production, refluxes were assessed by 24h-multiple intra-esophageal impedance measurements, simultaneous pH metry and continuous recording of oxygen saturation.

RESULTS

pH in the proximal and distal esophagus as well as six impedance channels were evaluated in all subjects. A mean of 129.4 refluxes per day per patient was detected. Complete and technically usable readings of oxygen saturation were obtained in 14 children. In this group the subjects had a mean of 112.6 refluxes and 92.6 desaturations per day per patient. The symptom index and symptom sensitivity index for acid refluxes were 34.7% and 24.6%, respectively, for non-acid refluxes 3.0% and 66.7%, respectively.

CONCLUSIONS

We found a high prevalence of acid reflux and a very low number of non-acid refluxes in this population. The symptom index was negative for all types of reflux, whereas the symptom sensitivity index was positive for both acid and non-acid reflux. Our data support a relation between acid gastro-esophageal refluxes and chronic pulmonary symptoms; however, this study does not support a role of non-acid reflux in children with respiratory symptoms, which are not on antacid medication.

Inappropriate prescribing of proton pump inhibitors in primary care

OBJECTIVES

To determine if an educational intervention initiated in secondary care can influence prescribing of proton pump inhibitors (PPIs) in the community.

METHODS

A prospective study of PPI use in patients admitted to medical wards in a university hospital. A simple educational intervention was employed to reduce inappropriate prescribing of PPIs in the community.

RESULTS

In the pre-intervention analysis 66/271 (24%) patients were receiving treatment with a PPI prescribed in the community. In 36/66 (54%) patients the PPI had been prescribed inappropriately. Six months after the intervention 91/344 (26%) patients were prescribed a PPI in the community. In only 45 of these 91 (49%) patients was there a recommended indication.

CONCLUSION

The intervention used in this study had no effect on the proportion of patients taking a PPI at the time of hospital admission or on the appropriateness of prescribing in the community.

Stress-ulcer prophylaxis for general medical patients: a review of the evidence

BACKGROUND

Gastric stress ulceration and bleeding are common occurrences in the critically ill and prophylactic acid-suppression is used almost universally in this population. Evidence suggests that general medical patients hospitalized outside of the intensive care unit often receive similar therapy.

PURPOSE

To determine how frequently general medical patients are prescribed stress ulcer prophylaxis and what evidence exists for doing so.

DATA SOURCE

The MEDLINE database (1966 to October 2005), the Cochrane Central Register of Controlled Trials (4th Quarter 2005), and the bibliographies of selected articles.

STUDY SELECTION

Studies that contained significant data about either the frequency of use of stress ulcer prophylaxis in general medical patients or gastrointestinal bleeding outcomes in patients given prophylaxis.

DATA EXTRACTION

The primary author extracted prevalence and outcome data.

DATA SYNTHESIS

Descriptive studies suggest that 20-25% of general medical patients receive acid suppression for stress ulcer prophylaxis in the absence of presumed (but not established) risk factors for bleeding. Only two randomized, controlled trials evaluated the effects of prophylaxis in this population. The first found a reduction in clinically significant gastrointestinal bleeding from 6% (3 of 48) with placebo to zero (n = 52) with magaldrate. The second found a reduction in clinically significant bleeding from 3% (2 of 70) with sucralfate to zero (n = 74) with cimetidine.

CONCLUSION

A significant number of general medical patients are prescribed acid-suppressive therapy for stress ulcer prophylaxis. The literature provides only sparse guidance on this issue with two randomized trials showing a possible benefit for prophylaxis. Further study is needed.

Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial

BACKGROUND

The proportion of proton pump inhibitor users on long-term therapy who can discontinue proton pump inhibitor (PPI) medication without developing symptoms is unknown.

AIM

To determine the proportion of patients on long-term PPI therapy who are able to discontinue PPIs without developing symptoms.

METHODS

Patients on long-term PPIs, without a history of peptic ulcer or esophagitis underwent upper endoscopy. Patients were randomized double-blindly to taper down or continue a constant dosage of omeprazole for three weeks. Thereafter, all patients discontinued PPIs.

RESULTS

Of the 97 patients enrolled, had used PPIs for 48 months, 78% had GERD. A total of 27% did not use PPIs during the year after discontinuation, 31% of the patients randomized to tapering discontinued PPIs and 22% of those who did not could discontinue therapy (NS). Gastro-oesophageal reflux disease (GERD) patients were more prone to continue PPIs than non-GERD patients. Only 16 (21%) of GERD patients were off PPIs vs. 48% of patients without GERD (p < 0.05). Serum gastrin was higher at baseline in GERD patients who resumed PPIs versus non-resumers (p < 0.05). GERD and serum gastrin were independent predictors of PPI requirement.

CONCLUSIONS

Discontinuation of PPI was successful in 27% of long-term PPI users. GERD patients had more difficulty discontinuing PPIs than non-GERD patients.

Prescribing of acid suppressive therapy: interactions between hospital and primary care

BACKGROUND

Overuse of acid suppressive therapy in the hospital setting and in primary care is well documented.

AIM

To describe interactions between prescriptions of acid suppressive therapy in hospital and in primary care.

METHODS

All patients admitted to hospital over a 24-month period were identified. Details about prescription of acid suppressive therapy were retrieved. All prescriptions of acid suppressive therapy redeemed by these patients 12 months before and after discharge were retrieved from a prescription database.

RESULTS

A total of 549 of 4477 patients (12.3%) were treated with acid suppressive therapy while in hospital, but acid suppressive therapy was prescribed de novo in only 192 (35%) of these cases. Information about indication for acid suppressive therapy and planned duration of therapy were given in the discharge letter in only 25% and 17% of the cases, respectively. Among patients treated with acid suppressive therapy during admission, prescriptions on acid suppressive therapy were redeemed by 67% in the year before admission and by 74% in the year after discharge. Among patients who had the acid suppressive therapy discontinued during admission (n = 67), 48% resumed acid suppressive therapy within the following 12 months. Of all subjects treated with acid suppressive therapy in the hospital catchment area, 7.8% were seen in our department.

CONCLUSIONS

Decisions about acid suppressive therapy prescribing in hospital has little influence on prescribing in primary care.

Inadequate use of acid-suppressive therapy in hospitalized patients and its implications for general practice

Acid-suppressive therapy (AST) is largely prescribed in both hospital and general practice setting but few data are available on appropriateness of AST use in hospitalized patients and its fallout on prescribing in general practice. We assessed AST in patients consecutively admitted to an internal medicine department to determine the type and timing of prescription and indication for use according to widely accepted guidelines. Prescriptions were rated as indicated, acceptable, or not indicated. Overall, 58.7% of 834 admitted patients received AST, mainly proton pump inhibitors. The prescriptions were indicated in 50.1% of patients, not indicated in 41.5%, and acceptable in 6.5%. The main reason for inappropriate use was prophylaxis in low-risk patients (64.8%). On admission, 35.7% of 112 patients already on AST were judged to receive inappropriate prescription; of 348 patients discharged on AST, overuse was identified in 38.5%. No significant difference was observed for inappropriate use at admission, during hospitalization, and at discharge. In 64 inpatients (7.7%) AST, although indicated, mainly for ulcer prophylaxis in high-risk patients, was not prescribed. In conclusion, AST is substantially over-used in both hospital and general practice settings, mainly for ulcer prophylaxis in low-risk patients. On the other hand, AST is underused in a small, but not negligible proportion of high-risk patients.