INTRODUCTION Overutilization of Proton pump inhibitors (PPI) in hospitalized patients is a well-recognized problem. In our previous study at St. Luke’s Hospital, we found that the lack of published guidelines for PPI use in non-critically ill patients results in overutilization of PPI in hospitalized patients. We conducted an educational intervention program to address this problem. DISCUSSION Overutilization of PPI in non-critically ill hospitalized patients is a known problem in medical practice. Use of PPI has been implicated in number of adverse consequences including but not limited to Clostridium difficile infection, pneumonia, and osteoporosis. In recent studies, PPI was found to be associated with increased in-hospital mortality, increased risk of cardiovascular events, dementia and chronic renal failure (CRF). We studied the magnitude of the problem in our hospital and employed an educational intervention program, which resulted in a significant reduction of inappropriate use of PPI in the hospital. There were several limitations to our study. This was a retrospective study where we noted a lack of proper documentation for outpatient use of PPI. We also were unable to precisely determine for how long the patients were taking PPI as outpatients. Our intervention included only medical residents (a total of 41), so we excluded data from NPs, hospitalists or PCPs after intervention. As a result, we are unable to determine the effect of the educational intervention on their practice. CONCLUSION PPIs have long been considered as relatively harmless drugs. In recent years, it has been implicated in several adverse effects that increases patient morbidity and mortality along with increased healthcare expenditure. Our data shows that proper education and ongoing surveillance, especially during admission and discharge can significantly reduce overutilization of PPI.

1. K. Gandhi, MD (Associate), S. Dhital, MD (Associate), S. Khan, MD (Associate), S. Basnyat, MD (Associate), F. Bofarrag, MD (Associate), T. Maduke, MD (Associate),
B. Qureshi, MD (Associate), Y. Goite, MD (Associate), F. Balis, MD (Fellow) and H. Kawsar, MD, Ph.D (Fellow)
Department of Medicine, St. Luke’s Hospital, Chesterfield, MO
A SEEMINGLY BENIGN DRUG IN THE SPOTLIGHT: AN EDUCATIONAL INTERVENTION TO REDUCE INAPPROPRIATE USE OF PPI
INTRODUCTION
Overutilization of Proton pump inhibitors (PPI) in hospitalized
patients is a well-recognized problem. In our previous study at
St. Luke’s Hospital, we found that the lack of published
guidelines for PPI use in non-critically ill patients results in
overutilization of PPI in hospitalized patients. We conducted an
educational intervention program to address this problem.
METHODS
We retrospectively reviewed 200 patient charts who received
PPI while admitted to the medical floor at St. Luke’s Hospital in
2014. It showed a high number of patients were on PPI
inappropriately. To improve this practice, we conducted an
interventional program to educate residents on appropriate use
of PPI by emails, flyers, holding brief meetings and providing
them with quick reference cards as well as by setting up high risk
pharmacy alert for Protonix use on EMR. The effect of this
intervention was measured by reviewing EMR of 179 qualified
patients admitted to medical floors between March and May
2016.
RESULTS
The majority of patients were Caucasian (90%) with female
predominance (56%). PPI was used or continued appropriately
in 92% (84%, pre intervention) patient during admissions and
85% (48%, pre intervention) during discharge. The most
common indications for PPI use in our study was gastro-
esophagitis or GERD (72%) and history of GI bleeding (12%).
Six percent of patients had a history of Barrett’s esophagus or
hiatal hernia. There was no documented reason for PPI use in
3% of patients, and 5% of them were discharged home on PPI.
DISCUSSION
Overutilization of PPI in non-critically ill hospitalized patients is a
known problem in medical practice. Use of PPI has been
implicated in number of adverse consequences including but not
limited to Clostridium difficile infection, pneumonia, and
osteoporosis.
DISCUSSION
In recent studies, PPI was found to be associated with increased
in-hospital mortality, increased risk of cardiovascular events,
dementia and chronic renal failure (CRF). We studied the
magnitude of the problem in our hospital and employed an
educational intervention program, which resulted in a significant
reduction of inappropriate use of PPI in the hospital.
There were several limitations to our study. This was a
retrospective study where we noted a lack of proper
documentation for outpatient use of PPI. We also were unable to
precisely determine for how long the patients were taking PPI as
outpatients. Our post interventional data was only from medical
residents (a total of 41), as a result, we are unable to determine
the effect of the educational intervention on the clinical practice
of NPs, hospitalists and PCPs.
CONCLUSION
PPIs have long been considered as relatively harmless drugs. In
recent years, it has been implicated in several adverse effects
that increases patient morbidity and mortality along with
increased healthcare expenditure. Our data shows that proper
education and ongoing surveillance, especially during admission
and discharge can significantly reduce overutilization of PPI.
REFERENCES
1. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. 1999;
56:347-79. 2. Chia, C., Lim, W, and Vu, C. (2014). Singapore Medical Journal Smedj, 55 (7),
363-366. 3. Hussain, S., Stefan, M., Visintainer, P. et al. (2010). Southern Medical Journal,
103(11). 4. Ladd, A., Panagopoulos, G., Cohen, J. et al. (2014). The American Journal of the
Medical Sciences, 347(6), 446-451. 5. Heidelbaugh, J., Kim, A., Chang, R. et al. Therapeutic
Advances in Gastroenterology, 219-232. 6. Lazarus, B, Chen. Y, Francis P. et al. (2016) JAMA
Intern Med. 2016;176(2) 7. 7.Gomm, W., Holt, V K, and Thomé, F (2016); JAMA Neurol.
2016;73(4):410- 416. 8. Protonix® (pantoprazole) prescribing information, Retrieved August 2015
ACKNOWLEDGEMENT
We would like to thank Dr. Daina Zhang, Dr. Belmaya Ghale, Dr. Luke Sung, Dr. Ali Entezari, and
Dr. Mohamed Gashouta for their contribution during pre-intervention phase of the study. We also
thank Dr. Sajid Zafar, MD, Department of Gastroenterology and Hepatology for his valuable
advice. Thanks to Ms. Tami Strand, Director of Clinical Performance and Improvement, and Mr.
Way Huey, Pharm D, BCPS, FCCM, Assistant Director of Pharmacy Services, for their help with
patient data.Residents NPs PCP Hospitalist
33%
30%
19%
16%
28%
24%
16%
29%
Prescribers of PPI
Inappropriate Appropriate
84%
16%
Appropriate Vs Inappropriate
Appropriate Inappropriate
48%
42%
10%
PPI on discharge
Continued Discontinued Unnown
Recommendations: Put a STOP Date
Additional
wks. if needed
Esophagitis/Gastritis/GERD – Erosive 8 weeks – STOP 4-8 weeks
Esophagitis/Gastritis/GERD - Nonerosive but symptomatic
Peptic Ulcer
Disease
Without H. Pylori 4-8 weeks – STOP 4 weeks
With H. Pylori
Triple/Dual therapy 14
days -STOP
14 days
>= 2 of minor
criteria
1. Severe sepsis
2. ICU stay more than 1 week
3. Occult GI bleeding for >=6 days
4. High Dose Glucocorticoid therapy
(Hydrocortisone>250, Prednisone >62.5,
methylprednisolone >50)
4 weeks – STOP 4 weeks
OTC use for Frequent heartburn Use for < 14 days – STOP May repeat after 4 months
Chronic NSAID therapy Continue daily – Max 6 months 6 months – STOP
Pathological hypersecretory conditions Daily – Possible lifetime use
STOP:
1. If C. Diff positive - until treatment completion
2. If does not know why taking it and denies dyspepsia
3. If acute interstitial nephritis develops
5%
85%
10%
PPI on discharge
Continued Discontinued Unknown
92%
3% 5%
Appropriate Vs Inappropriate
Appropriate Inappropriate Undetermined
Pre Post
16%
3%
84%
92%
PPI on Admission
Inappropriate Appropriate
Pre Post
42%
5%
48%
85%
PPI on Discharge
Continued Discontinued
Pre intervention Post intervention
Sample size 200 179
Age 72 72
Gender
Male 56% 44%
Female 44% 56%
Race
Caucasian 91% 90%
African-Americans 6% 8%
Others 3% 2%
72%
12%
6%
4%
3%3%
Reasons for PPI use
Esophagitis/Gastritis/
GERD
GI Bleeding
Hiatal hernia/Barrett's
esophagus
PUD/H.Pylori
Others
No Known Indication
Table 2. Patient characteristics
Table 1. Guidelines for PPI use