Use of Proton Pump Inhibitors in Nursing Facility Patients
Abstract & Commentary
By Malcolm Robinson, MD, FACP, FACG Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City Dr. Robinson reports no financial relationship to this field of study. This article originally appeared in the December 29, 2007 issue of Internal Medicine Alert. It was edited by Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD. Dr. Brunton is Clinical Professor, University of California, Irvine, and Dr. Roberts is Clinical Professor of Medicine, Albert Einstein College of Medicine. Dr. Brunton is a consultant for Sanofi-Aventis, Ortho-McNeil, McNeil, Abbott, Novo Norkisk, Eli Lilly, Endo, EXACT Sciences, and AstraZeneca, and serves on the speaker's bureau for McNeil, Sanofi-Aventis, and Ortho-McNeil. Dr. Roberts reports no financial relationship relevant to this field of study.
Synopsis: Many nursing home patients are admitted with prescriptions for proton pump inhibitors or H2-receptor antagonists without any obvious indication.
Source: Glew C, Rentler RJ. Use of proton pump inhibitors and other acid suppressive medications in newly admitted nursing facility patients. J Am Med Dir Assoc. 2007;8:607-609.
Hospitalized patients are often started on acid suppressive therapy for prophylaxis of stress ulceration and for other even less well-defined reasons. The authors of this paper note that inpatient stress ulcer prevention with acid suppression is rarely, if ever, indicated outside the intensive care setting, and they list several citations that corroborate the lack of evidence-based criteria for use of such therapy in a wide range of hospital settings. Worse yet, according to these authors and their review of pertinent literature, many patients who improperly receive PPIs and H2 receptor antagonists while hospitalized are also prescribed these drugs at discharge (including transfers to skilled nursing facilities). The present study involved a chart review of 98 admissions to a non-profit nursing home facility in Pennsylvania during the last half of 2006.
All available patient records for these admissions were reviewed, including hospital histories, physical examinations, medication lists, operative procedures, laboratory and radiological data, along with hospital discharge summaries. Appropriate indications for acid suppression were defined (admittedly arbitrarily) as GERD, UGI bleeding, peptic ulcer disease, and empirical treatment for any other unexplained GI bleeding. Since no patient identifiers were collected, no institutional review board approval was sought. Included in the record review were 63 women and 35 men. Only 9% of patients were younger than 74. Of the 98 patients, 61% were admitted with transfer orders, including a PPI; 3 other patients were on an H2 receptor antagonist (total of 64.3% on acid suppression). Only 50% of patients had an appropriate supporting diagnosis for such therapy (mostly GERD), and 3.1% of patients with the diagnosis of GERD were on no acid suppression. The authors comment that many of the accepted diagnoses could have been entirely inactive or even incorrect, and they suggest that the overall rate of unnecessary acid suppression is probably much higher than 50%. They state that even very "safe" drugs like PPIs sometimes lead to adverse events such a headache, diarrhea, and abdominal pain in some patients not to mention potential drug-drug interactions. It was concluded that discontinuation of acid suppression might be the most appropriate management for many if not most of these nursing home admissions.
Most physicians never see articles in journals like the Journal of the American Medical Directors Association, and they certainly don't seem to include the same level of peer review we see in most of the journals selected for Hospital Medicine Alert. The present study seems to exhibit a number of defects. It is quite small, and it could be argued that even this kind of chart review should have been submitted to an institutional review board for consideration. Furthermore, we all could verify that the discharge summaries and similar materials available for review at the time of nursing home admission may be grossly incomplete in terms of potentially meaningful historical detail. Nevertheless, it is the opinion of this reviewer that the conclusions of this brief report are fully justified. As they point out, the over-prescription of acid suppression in hospital settings and the continuation of such therapy post-discharge have been amply documented. It would be surprising if nursing home admissions did not share in the gross over-prescription of PPIs and H2RAs. These products have been heavily promoted, and they are perceived to be unusually safe. Physicians seem amazingly unconcerned with issues of cost containment, and many of them don't hesitate to prescribe expensive products (like PPIs) even for rather flimsy indications. Insurance companies and other payers would like to eliminate prescription of medications without some evidence-based supporting data. Physicians in general don't like challenges to their decisions, and they are particularly unwilling to provide detailed supportive data for every order written. Nevertheless, our society cannot afford endless increases in medical costs. If we don't regulate ourselves, it is certain that we will ultimately be subject to external regulation. Acid suppression probably is relatively safe, but it should only be prescribed for clear indications that can stand peer review. Unfortunately, once a patient has received a prescription for medication such as the acid suppressing agents, it is often unlikely that the prescription will be discontinued (particularly in the nursing home setting where physicians may have less historical connection with the patients under their care).