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THE UTILIZATION OF IV PROTON PUMP INHIBITORS (IV PPI): WHICH PATIENT POPULATION TO TARGET FOR A MORE APPROPRIATE PRACTICE?

W Afif, A Barkun, M Martel, C Dupont
BACKGROUND: There exist accepted indications for the use of IV PPI that are supported by high quality evidence.
AIM: To assess appropriateness of IV PPI treatment with regard to indications, dose and duration. Inappropriate use was defined as not supported by established guidelines.
METHODS: All patients receiving an IV PPI (Pantoprazole) in a tertiary care hospital, over a two-month period in 2004, were identified from a prospective pharmacy database and their charts reviewed retrospectively. Appropriate indications were use of IV PPI for upper gastrointestinal bleeding (UGIB group) following endoscopic hemostasis for high risk stigmata (or in those who could not undergo an endoscopy) (in both 80 mg bolus followed by 8 mg/h ´ 3 days), and fasting patients who met approved indications for an oral PPI (non-UGIB group) (40 mg daily). Awaiting endoscopy for UGIB was assessed as appropriate or inappropriate as part of a sensitivity analysis. We identified independent clinical, institutional and process-related predictors of inappropriate use with multivariate logistic regression.
RESULTS: One hundred seven patients received IV PPI, 50 (47%) in the UGIB group, and 57 (53%) in the non-UGIB group. Thirty-three (31%, 95% CI 22% to 41%) received appropriate therapy (indication, dose and duration), 61 (57%, 95% CI 47% to 67%) had an inappropriate indication, and 13 (12%, 95% CI 7% to 20%) an appropriate indication but incorrect treatment dose or duration. In the UGIB group, 21 (42%, 95% CI 28% to 57%) received appropriate therapy, compared with 12 (21%, 95% CI 12% to 34%) in the non-UGIB group. When considering IV PPI use while awaiting endoscopy for an UGIB as inappropriate, appropriate rates decreased from 33% to 18% (95% CI 11% to 26%). Among patients with an appropriate indication, under-dosing and over-dosing rates were similar (54% [95% CI 25% to 81%], and 46% [95% CI 19% to 75%], respectively). Significant independent predictors of inappropriate use were: increasing age and decreasing mean daily dose; time of day of the prescription just failed to reach significance.
CONCLUSION: Inappropriate utilization of IV PPI is frequent. IV PPI therapy was most often initiated inappropriately, and less so, prescribed for an incorrect dose or duration of time. IV PPI were used appropriately more often in the setting of UGIB. Improvement in the appropriateness of IV PPI use should target prescribing in older patients, those receiving lower mean daily doses, and perhaps, prescriptions written after hours.

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