Many people remain on PPIs uneccessarily


A major effort to tighten up on the overuse of proton pump inhibitors (PPIs) at the Sir Charles Gairdner Hospital in Western Australia has led to a 30% reduction in unnecessary medication use on discharge from ICU.

The initiative, reported at the inaugural Choosing Wisely Australia National Meeting, will reduce the potential for adverse effects from long-term use of PPIs such as esomeprazole and pantoprazole.

Intensivist Dr Matthew Anstey, chair of the Choosing Wisely Australia advisory group, said side effects from PPIs included ventilator-associated pneumonia, Clostridium difficile colitis, interstitial nephritis, iron and magnesium deficiencies.

“The incidence of these events is rare but if a lot of patients are on these drugs then we will see complications.”

He said an initial review of clinical practice across five ICUs in WA showed too many patients were started on the drugs for stress ulcer prophylaxis, and too few were taken off the drugs on discharge.

“We realised we were not good at following guidelines re: initiating PPI therapy and not great at stopping it either. Prescribing patterns and deprescribing opportunities were random and not evidence based,” Dr Anstey told the limbic.

The review found about 44% of patients started on PPI for stress ulcer prophylaxis were still on the medication at discharge without any indication for its use. They estimated the Australia-wide cost of unnecessary PPI use at $22.4 million per year.

Dr Anstey said a subsequent intervention in Sir Charles Gairdner’s ICU included the development of a deprescribing algorithm and an education campaign for medical, nursing and pharmacy staff.

“Being admitted to hospital is an opportunity to rationalise medications. Pharmacists are doing the medication reconciliation and were therefore allowed to cross out PPIs on discharge if the indication had been prophylaxis.”

The project was supported by the addition of a mandatory field for instructions to GPs in electronic discharge summaries.

Dr Anstey said a hospital wide effort to reduce PPI use had been less effective despite building the information into the orientation and online resources for junior medical doctors.

“We’re not sure why but it could be that patients move in and out quickly in other units and its easier for people to abrogate responsibility. Instead they delegate back to the GP.”

He said the pendulum had swung too far towards everyone getting PPI therapy instead of those who needed it most.

“In ICU, patients who are ventilated for more than 48 hours or are at risk of bleeding due to a coagulopathy benefit from stress ulcer prophylaxis. If they are being fed by nasogastric tubes then they don’t need prophylaxis as food is protective to the mucosa.”

“In outpatients, most people use PPIs for GORD or oesophagitis. This should be short term use, at the lowest dose or on demand and stopped when symptoms are controlled.”

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