GI tract

Inappropriate PPI use widespread in haematology patients

Evidence of wide variation in the use of proton pump inhibitors (PPIs) as prophylaxis in haematology patients raises concerns about unnecessary costs and the risk of adverse events.

A retrospective review of prescribing practices at the Austin Hospital over 14 months found about 60% of myeloma, lymphoma and autograft patients received PPI prophylaxis during and beyond chemotherapy without an accepted indication.

“By far the most common inappropriate indication for prescribing PPIs was in conjunction with steroids below the appropriate risk dose. Typically, every steroid prescription was accompanied with a PPI regardless of steroid dose and continued well beyond the cessation of the steroid,” the researchers wrote in the Internal Medicine Journal.

The review found 32% of multiple myeloma patients were already on PPIs prior to the commencement of chemotherapy however only a third of those patients had an appropriate indication for PPIs.

Seventy percent of patients were prescribed a PPI at the commencement of chemotherapy yet only 40% had an appropriate indication. Almost half the patients continued PPIs beyond the duration of their chemotherapy.

Similarly for lymphoma patients, 35% were on PPIs prior to their chemotherapy with just over half (56%) having a documented indication for their use.

Most patients (79%) were prescribed PPIs before induction; only 20% with an appropriate indication. At the completion of chemotherapy, almost half (46%) continued to take PPIs for an indefinite period.

Most autologous transplant patients (65%) also received a PPI during their inpatient stay and almost all continued with therapy on discharge, with 58% of those not having an appropriate indication.

No myeloma or autograft patients had an adverse GI event but 4% of lymphoma patients – all on PPIs – did.

As well, the findings of an informal survey of haematology units around Australia have highlighted the wide variation in PPI use in a number of clinical scenarios including chemotherapy with high dose steroids or expected mucositis and thrombocytopenia.

The survey found none of the units had a protocol for PPI use.

“The literature provides virtually no useful evidence to guide their use in the various contexts relevant to these patients, which is reflected in the paucity of guidelines and the substantial variation in clinical practice amongst haematologists,” the review article said.

However it is possible to change practice as demonstrated by an intervention at the Austin hospital, the authors suggested.

A preliminary evaluation of education supported by pop-up reminders of accepted indications for prescribing PPIs has shown about a 20% reduction in inappropriate prescribing or smaller doses, without an increased in GI adverse events.

Director of haematology Professor Andrew Grigg told the limbic a formal evaluation of the intervention was still underway.

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