5/5/2015
Stress Ulcers
• Pathophysiology
Assessment of Appropriate Use of
Stress Ulcer Prophylaxis in Acute
Medically Ill Patients
Jiwon Roh, Pharm.D.
PGY1 Pharmacy Resident
Harper University Hospital, Detroit Medical Center
– Acute superficial inflammatory lesions of the
gastric lining
– Impaired gastric mucosal protection from poor
perfusion caused by intense physiologic
stress
• Complication
– Overt GI bleeding
• Stress ulcer prophylaxis (SUP)
The speaker has no actual or potential conflicts of interest in relation to this presentation.
Overuse of Acid Suppressing Drugs
in Non-ICU
• Qadeer et al. (n=17,707) patients admitted to
general medicine service
– Incidence of hospital-acquired GI bleeding  0.4%
– No protective benefit seen with prophylactic use
• Stress ulcer prophylaxis (SUP) not routinely
indicated in this population
• Acid suppression therapy in non-ICU patients
measured to be up to 70%
– PPI, H2 blocker, Sucralfate
Anderson ME. Hosp Med Clin 2013:e32-e44
Consequences of Overuse for Inpatients
Inappropriate
continuation
on hospital
discharge
Unnecessary costs
• Heidelbaugh et al. (n=1870 general medicine
patients) – inappropriate SUP use increased
annual inpatient and outpatient costs $111,791
Herzig SJ. JAMA 2009;301:2120-28
Qadeer MA. J Hosp Med. 2006;1:13-20
Risk Factors for Nosocomial
Upper GI Bleeding in Non-ICU
Excluding patients receiving scheduled surgery/procedures,
obstetrics/gynecology, neurology, and psychiatry patients
Herzig SJ 2013. J Gen Intern Med 28(5):683-90
Heidelbaugh JJ 2006. Am J Gastroenterol 101(10):2200-5
Hypothesis
• Herzig et al. (n=75,723) patients admitted to
general medicine service
†
Adverse outcomes
• Opportunistic infections
- C. difficile
- Pneumonia
• Vitamin B12 deficiency
• Bone fracture
Risk score
NNT
≤ 7 points
500
8-9 points
179
10-11 points
95
≥ 12 points
48
• SUP is overused in acute medically ill
patients
• Revising SUP guidelines will lead to more
appropriate prescribing of SUP during
hospital stay and at patient discharge
Herzig SJ 2013. J Gen Intern Med 28(5):683-90
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5/5/2015
Step1. DMC SUP Scoring system
Objective
• To assess the impact of revised guidelines
on SUP prescribing practices
Revised SUP
guidelines into effect
August 2014
Dose
40mg PO or IV
Ranitidine
150mg PO
50mg IV
Sucralfate
1g PO
CrCl
No renal
adjustment
≥ 50mL/min
< 50mL/min
≥ 50mL/min
< 50mL/min
No renal
adjustment
October – November 2014
Step 2: Education
SUP Agent Recommendations
Medication
Pantoprazole
Herzig SJ 2013. J Gen Intern Med 28(5):683-90
September 2014
Regimen
Daily
BID
Daily
TID
BID
QID
H2 blockers have been shown to have similar rates of prevention of upper GI bleed,
pneumonia, C.difficile infection, and length of stay in ICU when compared to protonpump inhibitors
• Emailed medical staffs revised SUP guidelines
• Guidelines posted on pharmacy website and all
DMC computer screensavers
• Provided education to physicians and
pharmacists at scheduled didactic conferences
Revised guidelines
Into effect
August 2014
Education
September 2014
October – November 2014
Step 3: Analysis of SUP
Methods – Patient Criteria
• Retrospective chart review
Inclusion
– Harper University Hospital or Hutzel Women’s
Hospital
– Pre-intervention: Oct – Nov 2013
– Post-intervention: Oct – Nov 2014
Revised guidelines
Into effect
August 2014
Education
September 2014
Analysis of SUP
- Adult (18+ years)
- Received SUP agents during inpatient admissions
Exclusion
- Admission to the ICU
- Active or suspected acute GI bleeding
- History of GERD, peptic ulcer disease, or erosive
esophagitis
- Acid suppressive therapy at home
October – November 2014
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Endpoints
Statistical Analysis
Primary
• Descriptive statistics
• Chi-squared analysis or Fisher’s exact test
for parametric data
• P < 0.05 for statistical significance
- The proportion of patients who received SUP that
met the criteria for SUP use
Secondary
- The proportion of patients that received
discharge orders for SUP
- The proportion of patients that had adverse
outcomes related to SUP medications
Study Population
Excluded Patients
Pre-intervention
N= 464
Post-intervention
N= 481
ICU admission, n(%)
Excluded
N = 326
Excluded
N = 315
138 (30%)
patients met
inclusion criteria
166 (35%)
patients met
inclusion criteria
Active or suspected acute
GI bleeding, n(%)
25 (7.7)
26 (8.3)
0.88
History of GERD/PUD/
Erosive esophagitis, n(%)
Outpatient SUP
medications, n(%)
127 (39.0)
119 (37.8)
0.81
226 (69.3)
235 (74.6)
0.16
Risk Factors
Baseline Characteristics
90
Preintervention
(n=138)
Postintervention
(n=166)
58 (42)
80 (58)
71 (43)
95 (57)
58.9 ± 18.1
56.9 ±16.9
Gender
Male, n(%)
Female, n(%)
Age
Years, mean ± SD
Race
African American, n(%)
Caucasian, n(%)
Others or unknown, n(%)
107 (77.5)
18 (13.0)
13 (9.4)
129 (77.7)
27 (16.3)
10 (6.0)
Days, mean ± SD
7.21 ± 5.8
6.75 ±4.7
Length
of stay
80
Percentage of Patients
Characteristics
PrePostpintervention intervention value
(n=326)
(n=315)
18 (5.5)
30 (9.5)
0.07
Pre-intervention (n=138)
Post-intervention (n=166)
70
60
50
40
30
20
10
0
Risk
Factors
p > 0.05
PPxAC: Prophylactic anticoagulation, p > 0.05
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Risk Score Distribution
SUP Prescribed Inpatient
Pre-intervention (n=138)
60
Percentage of Patients
Preintervention
(n=138)
Post-intervention (n=166)
48.6% 47.6%
p = 0.75
50
32.6%
40
p-value
PPI, n(%)
38 (27.5)
43 (25.9)
0.80
H2 blocker, n(%)
Appropriate renal dosing
100 (72.5)
91( 91)
123 (74.1)
120 (96)
0.80
0
0
1.00
129 (93.5)
140 (84.3)
0.02
33.7%
30
Sucralfate, n(%)
20
10
Postintervention
(n=166)
11.6% 12.0%
Order within 24 hours of hospital
admission, n(%)
7.2% 6.6%
0
0 to 3
4 to 7
8 to 10
≥ 11
Risk Score Range
Reported Adverse Outcomes
SUP Prescribed at Discharge
Pre-intervention
(n=138)
Post-intervention
(n=166)
Discharge SUP medications, n(%)
27 (22)
27 (16)
Potential indications, n(%)
7 (5.1)
13 (7.8)
• GERD/H.pylori/PUD
2 (1.5)
2 (1.2)
• GI/Rectal bleeding
3 (2.2)
2 (1.2)
• Discharge to rehab
1 (0.7)
4 (2.4)
• Bariatric surgery
1 (0.7)
1 (0.6)
• Chronic steroid use
Unknown indications, n(%)
0 (0)
4 (2.4)
20 (14.5)
14 (8.4)
• No cases of hospital-acquired pneumonia
or Clostridium difficile infection were
documented
p = 0.46
Conclusions
• Inappropriate use of SUP remains common in
hospital practice
• At least 8% were discharged home on SUP
without an acceptable indication
• Need to promote appropriate use of SUP and
decrease unnecessary use of SUP
Study Limitations
• Small sample size
• Retrospective chart review
• Barrier to education
– Reaching out to all providers
– Brief education session
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Future plans
• Medication reconciliation
• About 70% of patients were using SUP prior to
admission
• Interventions to improve prescribing
patterns
• Educational materials
• Pharmacist participation on rounds
• Revise protocol
Self-assessment Questions
1. Which factor is not included in the SUP
risk score calculation?
a) liver disease
b) acute renal failure
c) female
d) age > 60 years
• Awaiting release of guideline
Self-assessment Questions
Self-assessment Questions
1. Which factor is not included in the SUP
risk score calculation?
2. Which of following adverse outcomes is
not associated with inappropriate use of
SUP?
a) liver disease
b) acute renal failure
c) female
d) age > 60 years
a) Clostridium difficile infection
b) pneumonia
c) osteoporosis
d) none of these
Self-assessment Questions
Acknowledgements
2. Which of following adverse outcomes is
not associated with inappropriate use of
acid-suppression therapy?
I would like to thank the following mentors
for all of their expertise and assistance with
this project:
Angela Milad, B.S.Pharm
Cheryl Szabo, Pharm.D., BCPS
Sheila Wilhelm, Pharm.D., BCPS
a) Clostridium difficile infection
b) pneumonia
c) osteoporosis
d) none of these
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5/5/2015
Assessment of Appropriate Use of
Stress Ulcer Prophylaxis in Acute
Medically Ill Patients
Jiwon Roh, PharmD; Hana Alawy, Pharm.D. Candidate
2015, Cheryl Szabo, Pharm.D., BCPS, Angela Milad,
B.S.Pharm, Sheila Wilhelm, Pharm.D., BCPS
The speaker has no actual or potential conflicts of interest in relation to this presentation.
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