Download - GI prophylaxis - Should I order it or not -
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• 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
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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
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• 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
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• 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.
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• 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
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• 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
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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)
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• NONE !!!
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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
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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
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• 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
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• 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
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* There were 5-7 patients who were placed on PPI as outpatient without indications
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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
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• 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
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• 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