• 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

A. 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.

B. 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation.

C. 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.

D. 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation.

E. 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.

F. None of the above

• 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

• 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.

• 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

• 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

Major risk (need at least 1)• 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)

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)

• NONE !!!

A. 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.

B. 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation.

C. 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.

D. 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation.

E. 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.

F. None of the above

A. 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.

B. 75yo obese female w/ DMII, HTN, HLD, and COPD p/w COPD exacerbation caused by community acquired pneumonia requiring 1 day of intubation.

C. 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.

D. 45yo female w/ HIV and found to have CBS lymphoma started on low dose dexamethasone and palliative brain radiation.

E. 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.

F. None of the above

• 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

• 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

* There were 5-7 patients who were placed on PPI as outpatient without indications

Inpatient• 40mg IV = $3.75/inj• 40mg PO = $0.22/tab• 20mg PO = $0.1/tab

Outpatient• 40mg PO = $0.05 /tab• 20mg PO = < $0.05/tab

• 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

• 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