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Variables Associated with Stress Ulcer Prophylaxis Misuse: A Retrospective Analysis

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Abstract

Background

Stress ulcer prophylaxis (SUP) is commonly used in hospitals. Although its indications are better delineated for intensive care unit (ICU) patients, its use in non-ICU settings is somewhat arbitrary and based on judgment.

Objective

We attempted to assess the extent of SUP overuse in our hospital. We also carefully collected and analyzed several variables to detect associations governing this flawed behavior and its financial burden on the hospital’s budget.

Materials and Methods

We retrospectively analyzed charts of patients admitted to the medical floor of a tertiary referral university hospital over a 1 year period. All adult patients admitted to the medical ward who received at least one dose of SUP were included and reviewed for a multitude of variables in addition to the appropriateness of acid suppression therapy (AST).

Results

We included 320 charts and found that 92% of patients admitted during that period were not eligible for SUP. The total inappropriateness of SUP was noted to be 58% (p = 0.015). Increasing age and male gender were found to be significant variables in AST misuse (p = 0.045 and p = 0.010), much like duration of hospital stay (p = 0.008). Comorbidities was also found to be a defining variable for AST overuse (odds ratio [OR] = 3.27). Patients with two or more minor risk factors were also subjected more to SUP inappropriately (OR = 3.53), in addition to patients of certain specialties (Neurology, Infectious Diseases, etc.). Our calculated financial burden was more than $23,000 per year for the medical floor.

Conclusion

This retrospective study confirmed the growing suspicion that SUP misuse is evident on the medical floors. We also delineated several factors and variables associated with and affecting SUP overuse.

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References

  1. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm. 2007;64:1396–1400.

    Article  PubMed  Google Scholar 

  2. Ali T, Harty RF. Stress-induced ulcer bleeding in critically ill patients. Gastroenterol Clin North Am. 2009;38:245–265.

    Article  PubMed  Google Scholar 

  3. Nasser SC, Nassif JG, Dimassi HI. Clinical and cost impact of intravenous proton pump inhibitor use in non-ICU patients. World J Gastroenterol. 2010;16:982–986.

    Article  PubMed  CAS  Google Scholar 

  4. Quenot J-P, Thiery N, Barbar S. When should stress ulcer prophylaxis be used in the ICU? Curr Opin Crit Care. 2009;15:139–143.

    Article  PubMed  Google Scholar 

  5. ASHP Therapeutic 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 

  6. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol. 2009;104:S27–S32.

    Article  PubMed  CAS  Google Scholar 

  7. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994;330:377–381.

    Article  PubMed  CAS  Google Scholar 

  8. Sesler JM. Stress-related mucosal disease in the intensive care unit: an update on prophylaxis. ACCN Adv Crit Care. 2007;18:119–128.

    Article  Google Scholar 

  9. Farrell CP, Mercogliano G, Kuntz CL. Overuse of stress ulcer prophylaxis in the critical care setting and beyond. J Crit Care. 2010;25:214–220.

    Article  PubMed  Google Scholar 

  10. Terzi Coelho CB, Dragosavac D, Coelho Neto JS, Montes CG, Guerrazzi F, Andreollo NA. Ranitidine is unable to maintain gastric pH levels above 4 in septic patients. J Crit Care. 2009;24:627.e7–627.e13.

    Article  Google Scholar 

  11. Judd WR, Davis GA, Winstead PS, Steinke DT, Clifford TM, Macaulary TE. Evaluation of continuation of stress ulcer prophylaxis at hospital discharge. Hosp Pharm. 2009;44:888–893.

    Article  Google Scholar 

  12. Afif W, Alsulaiman R, Martel M, Barkun AN. Predictors of inappropriate utilization of intravenous proton pump inhibitors. Aliment Pharmacol Ther. 2007;25:609–615.

    Article  PubMed  CAS  Google Scholar 

  13. Khalili H, Dashti-Khavidaki S, Hossein Talasaz AH, Tabeefar H, Hendoiee N. Descriptive analysis of a clinical pharmacy intervention to improve the appropriate use of stress ulcer prophylaxis in a hospital infectious disease ward. J Manag Care Pharm. 2010;16:114–121.

    PubMed  Google Scholar 

  14. Slattery E, Theyventhiran R, Cullen G, et al. Intravenous proton pump inhibitor use in hospital practice. Eur J Gastroenterol Hepatol. 2007;19:461–464.

    Article  PubMed  CAS  Google Scholar 

  15. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006;1:13–20.

    Article  PubMed  Google Scholar 

  16. Nardino RJ, Vender RJ, Herbert PN. Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol. 2000;95:3118–3122.

    PubMed  CAS  Google Scholar 

  17. Zink DA, Pohlman M, Barnes M, Cannon ME. Long-term use of acid suppression started inappropriately during hospitalization. Aliment Pharmacol Ther. 2005;21:1203–1209.

    Article  PubMed  CAS  Google Scholar 

  18. Lee EY, Brotz C, Greenwald D. Cost and characteristics of intravenous proton pump inhibitor use and misuse in a tertiary care hospital. Am J Gastroenterol. 2003;98:S54.

    Google Scholar 

  19. Yap KB, Chan KM. The prescribing pattern of hospital doctors. Singapore Med J. 1998;39:496–500.

    PubMed  CAS  Google Scholar 

  20. George CJ, Korc B, Ross JS. Appropriate proton pump inhibitor use among older adults: a retrospective chart review. Am J Geriatr Pharmacother. 2008;6:249–254.

    Article  PubMed  CAS  Google Scholar 

  21. Carey IM, De Wilde S, Harris T, et al. What factors predict potentially inappropriate primary care prescribing in older people? Analysis of UK primary care patient record database. Drugs Aging. 2008;25:693–706.

    Article  PubMed  Google Scholar 

  22. Craig DGN, Thimappa R, Anand V, Sebastian S. Inappropriate utilization of intravenous proton pump inhibitors in hospital practice—a prospective study of the extent of the problem and predictive factors. QJM. 2010;103:327–335.

    Article  PubMed  CAS  Google Scholar 

  23. Alsultan MS, Mayet AY, Malhani AA, Alshaikh MK. Pattern of intravenous proton pump inhibitors use in ICU and non-ICU setting: a prospective observational study. Saudi J Gastroenterol. 2010;16:275–279.

    Article  PubMed  Google Scholar 

  24. Mayet AY. Improper use of antisecretory drugs in a tertiary care teaching hospital: an observational study. Saudi J Gastroenterol. 2007;13:124–128.

    Article  PubMed  Google Scholar 

  25. Cook DJ, Witt LG, Cook RJ, Guyatt GH. Stress ulcer prophylaxis in the critically ill: a meta-analysis. Am J Med. 1991;91:519–527.

    Article  PubMed  CAS  Google Scholar 

  26. Cook DJ, Reeve BK, Guyatt GH, et al. Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. JAMA. 1996;275:308–314.

    Article  PubMed  CAS  Google Scholar 

  27. Cash BD. Evidence-based medicine as it applies to acid suppression in the hospitalized patient. Crit Care Med. 2002;30:S373–S378.

    Article  PubMed  Google Scholar 

  28. Perwaiz MK, Posner G, Hammoudeh F, et al. Inappropriate use of intravenous PPI for stress ulcer prophylaxis in an inner city community hospital. J Clin Med Res. 2010;2:215–219.

    PubMed  Google Scholar 

  29. Conn HO, Poynard T. Corticosteroids and peptic ulcer: meta-analysis of adverse events during steroid therapy. J Intern Med. 1994;236:619–632.

    Article  PubMed  CAS  Google Scholar 

  30. Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. Ann Intern Med. 1991;114:735–740.

    Article  PubMed  CAS  Google Scholar 

  31. Jung R, MacLaren R. Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. Ann Pharmacother. 2002;36:1929–1937.

    Article  PubMed  CAS  Google Scholar 

  32. Kantorova I, Svoboda P, Scheer P, et al. Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology. 2004;51:757–761.

    PubMed  Google Scholar 

  33. Aymard JP, Aymard B, Netter P, Bannwarth B, Trechot P, Streiff F. Haematological adverse effects of histamine H2-receptor antagonists. Med Toxicol Adverse Drug Exp. 1988;3:430–448.

    Article  PubMed  CAS  Google Scholar 

  34. Penston J, Wormsley KG. Adverse reactions and interactions with H2-receptor antagonists. Med Toxicol. 1986;1:192–216.

    PubMed  CAS  Google Scholar 

  35. Driks MR, Craven DE, Celli BR, et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization. N Engl J Med. 1987;317:1376–1382.

    Article  PubMed  CAS  Google Scholar 

  36. Messori A, Trippoli S, Vaiani M, Gorini M, Corrado A. Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials. BMJ. 2000;321:1103–1106.

    Article  PubMed  CAS  Google Scholar 

  37. Gerson LB, Triadafilopoulos G. Proton pump inhibitors and their drug interactions: an evidence-based approach. Eur J Gastroenterol Hepatol. 2001;13:611–616.

    Article  PubMed  CAS  Google Scholar 

  38. Martin RM, Dunn NR, Freemantle S, Shakir S. The rates of common adverse events reported during treatment with proton pump inhibitors used in general practice in England: cohort studies. Br J Clin Pharmacol. 2000;50:366–372.

    Article  PubMed  CAS  Google Scholar 

  39. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301:2120–2128.

    Article  PubMed  CAS  Google Scholar 

  40. Cunningham R, Dale B, Undy B, Gaunt N. Proton pump inhibitors as a risk factor for Clostridium difficile diarrhoea. J Hosp Infect. 2003;54:243–245.

    Article  PubMed  CAS  Google Scholar 

  41. Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case–control studies. CMAJ. 2004;171:33–38.

    Article  PubMed  Google Scholar 

  42. Louie TJ, Meddings J. Clostridium difficile infection in hospitals: risk factors and responses. CMAJ. 2004;171:45–46.

    Article  PubMed  Google Scholar 

  43. Donskey CJ. The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens. Clin Infect Dis. 2004;39:219–226.

    Article  PubMed  Google Scholar 

  44. Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol. 2007;102:2047–2056.

    Article  PubMed  Google Scholar 

  45. Erstad BL. Proton-pump inhibitors for acute peptic ulcer bleeding. Ann Pharmacother. 2001;35:730–740.

    Article  PubMed  CAS  Google Scholar 

  46. Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006;101:2200–2205.

    Article  PubMed  Google Scholar 

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Conflict of interest

The authors report no conflict of interest in this trial. They have received no financial support.

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Authors and Affiliations

  1. Department of Pharmacology, Division of Pharmacy, Beirut Arab University, Beirut, Lebanon

    Ola Soubra, Hania Nakkash & Lama Soubra

  2. Department of Internal Medicine, Division of Gastroenterology, Rafik Hariri University Hospital, Specialty Clinics Center, 4B Hamra, Beirut, 2034-7304, Lebanon

    Iyad A. Issa

Authors
  1. Iyad A. Issa
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  2. Ola Soubra
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  3. Hania Nakkash
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  4. Lama Soubra
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Correspondence to Iyad A. Issa.

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Issa, I.A., Soubra, O., Nakkash, H. et al. Variables Associated with Stress Ulcer Prophylaxis Misuse: A Retrospective Analysis. Dig Dis Sci 57, 2633–2641 (2012). https://doi.org/10.1007/s10620-012-2104-9

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  • DOI: https://doi.org/10.1007/s10620-012-2104-9

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