INAPPROPRIATE USAGE OF INTRAVENOUS PROTON PUMP INHIBITORS AND ASSOCIATED FACTORS IN A HIGH COMPLEXITY HOSPITAL IN BRAZIL

BISCHOFF, Laura M; FARACO, Laura S M; MACHADO, Lucas V; BIALECKI, Alex V S; ALMEIDA, Gabriel M de; BECKER, Smile C C

doi:10.1590/S0004-2803.202100000-07

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ORIGINAL ARTICLE • Arq. Gastroenterol. 58 (01) • Jan-Mar 2021 • https://doi.org/10.1590/S0004-2803.202100000-07 copy

INAPPROPRIATE USAGE OF INTRAVENOUS PROTON PUMP INHIBITORS AND ASSOCIATED FACTORS IN A HIGH COMPLEXITY HOSPITAL IN BRAZIL

Uso inapropriado de inibidores de bomba de prótons intravenosos e fatores associados em um hospital de alta complexidade no Brasil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Intravenous (IV) use of proton pump inhibitors (PPIs) is advised only in cases of suspected upper gastrointestinal bleeding (UGIB) or impossibility of receiving oral medication, although there has been a persistent practice of their inappropriate use in health institutions.

OBJECTIVE:

The purpose of our study was to measure the inappropriate use of IV PPIs in a high complexity hospital in Brazil and to estimate its costs.

METHODS:

Retrospective study of 333 patients who received IV omeprazole between July and December of 2018 in a high complexity hospital in Brazil.

RESULTS:

IV omeprazole was found to be appropriately prescribed in only 23.4% patient reports. This medication was administered mainly in cases of suspected UGIB (19.1%) and stress ulcer prophylaxis in patients with high risk of UGIB unable to receive medication orally (18.7%). It was observed a statistically significant association between adequate prescription and stress ulcer prophylaxis in patients with high risk of UGIB unable to receive medication orally; patient nil per os with valid indication for PPIs usage; prescription by intensive care unit doctors; prescription by emergency room doctors; intensive care unit admission; evolution to death; sepsis; and traumatic brain injury (P<0.05). On the other hand, inadequate prescription had a statistically significant association with surgical ward prescription and non-evolution to death (P<0.05). The estimated cost of the vials prescribed inadequately was US$1696.

CONCLUSION:

There was a high number of inappropriate IV omeprazole prescriptions in the studied hospital, entailing greater costs to the institution and unnecessary risks.

HEADINGS:
Proton pump inhibitors; Peptic ulcer; Gastrointestinal hemorrhage; Inappropriate prescribing; Off-label use; Endoscopy; Medical overuse

	Mean ±SD, n (%)
	n=320
Age (years)	59.92±16.29

Sex
Male	174 (54.4)
Female	146 (45.6)

Race
White	298 (93.4)
Black	11 (3.4)
Brown	9 (2.8)
Indigenous	1 (0.3)
Not specified	1

Comorbities
Systemic arterial hypertension	125 (39.1)
Pneumonia	81 (25.3)
Diabetes Mellitus	76 (23.8)
Malignant neoplasia	62 (19.4)
Acute coronary syndrome	45 (14.1)
Sepsis	44 (13.8)
Cerebrovascular accident	28 (8.8)
COPD	20 (6.3)
Congestive heart failure	15 (4.7)
Chronic hepatopathy	15 (4.7)
Traumatic brain injury	12 (3.8)
UTI	10 (3.1)
Gallstones	9 (2.8)
Chronic kidney disease	9 (2.8)
Other	95 (29.7)

	n (%), Median
	(minimum - maximum)
	n=320
Adequate indications
Upper gastrointestinal bleeding suspicion	61 (19.1)
Stress ulcer prophylaxis in patient with high risk of UGIB unable to receive orally	60 (18.7)
Patient in NPO with valid PPI indication	12 (3.7)

Inadequate indications
PUD prophylaxis after surgical procedure	58 (18.1)
Stress ulcer prophylaxis in patients with low risk of UGIB	40 (12.5)
Abdominal pain	23 (7.2)
Absence of clear indication	19 (5.9)
Stress ulcer prophylaxis and high risk of UGIB with possibility of oral administration	12 (3.7)
Anticoagulants/ platelet antiaggregant/anti-inflammatories usage	11 (3.4)
Abdominal pain associated with vomiting	8 (2.5)
Other	16 (5.0)

Duration of treatment (days)	4.00 (1-61)

	n (%)
	n=320
Prescribing sector
ICU	127 (39.7)
General medicine	81 (25.3)
Surgery	56 (17.5)
Oncology	18 (5.6)
Gastroenterology	16 (5.0)
Cardiology	8 (2.5)
Pneumology	5 (1.6)
Other	9 (2.8)

Prescription by ER doctor
Yes	33 (10.3)
No	287 (89.7)

Admission in the ICU during hospital stay
Yes	160 (50.0)
No	160 (50.0)

Evolution to death
Yes	69 (21.6)
No	251 (78.4)

	n (%)
	n=61
Procedure
UDE	38 (62.3)
Surgery	2 (3.3)
Gastric or duodenal perforated ulcer	2 (100.0)
Not performed	21 (34.4)

Reason for not performing any procedure (n=21)
Critically ill patient	6 (28.6)
Recent UDE	4 (19.0)
Unnecessary UDE or patient too well for procedure	4 (19.0)
Not informed	7 (33.4)

UDE results (n=38)
Normal or unspecific findings	12 (31.6)
Peptic ulcer disease with stigmata of low risk of rebleeding (Forrest IIC or III)	10 (26.3)
Peptic ulcer disease with stigmata of high risk of rebleeding (Forrest IA, IB, IIA or IIB)	8 (21.1)
Gastro-esophageal varicose veins	3 (7.9)
Esophagogastric mucous membrane erosive disease without active bleeding	2 (5.3)
Esophagogastric mucous membrane erosive disease with active bleeding	1 (2.6)
Tumoral lesion with active bleeding	1 (2.6)
Gastric angiodysplasia without signs of recent bleeding	1 (2.6)

Medication suspended in up to 48h in case of absence of indication for maintenance of intravenous omeprazole (n=28)
Yes	19 (67.8)
No	9 (32.2)

	n (%)
	n=320
Adequate indication
Yes	133 (41.6)
No	187 (58.4)

Adequate dosage*
Yes	93 (29.1)
No	227 (70.9)

Adequate duration*
Yes	101 (31.6)
No	219 (68.4)

Entirely adequate prescription
Yes	75 (23.4)
No	245 (76.6)

	n (%)		P-value
	Adequate prescription	Inadequate prescription
Adequate indications	n=74	n=180
Suspected upper gastrointestinal bleeding	19 (31.1)	42 (68.9)	<0.001^†
Stress ulcer prophylaxis in patient with high risk of UGIB unable to receive orally	44 (73.3)^a	16 (26.7)
Patient in NPO and valid indication for PPI usage	11 (91.7)^a	1 (8.3)
Prescribing sector	n=75	n=223
ICU	44 (34.6)^a	83 (65.4)	0.010^†
General medicine	18 (22.2)	63 (77.8)
Surgery	7 (12.5)	49 (87.5)^a
Prescription by ER doctor	n=75	n=245
Yes	15 (45.5)^a	18 (54.5)	0.002^‡
No	60 (20.9)	227 (79.1)^a
ICU admission	n=75	n=245
Yes	50 (31.3)^a	110 (68.8)	0.001^‡
No	25 (15.6)	135 (34.4)^a
Evolution to death	n=75	n=245
Yes	31 (44.9)^a	38 (55.1)	<0.001^‡
No	44 (17.5)	207 (82.5)^a
Sepsis
Yes	23 (54.5)^a	20 (45.5)	<0.001^‡
No	51 (18.5)	225 (81.5)^a
Traumatic brain injury
Yes	8 (66.7)^a	4 (33.3)	0.001^†
No	67 (21.8)	241 (78.2) ^a

Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
E-mail: secretariaarqgastr@hospitaligesp.com.br

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[1] Corresponding author: Laura Bischoff. E-mail: lauramarconbischoff@gmail.com