Indication of acid suppression therapy and predictors for the prophylactic use of proton-pump inhibitors vs. histamine-2 receptor antagonists in a Malaysian tertiary hospital
Background: Proton-pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are common acid suppressants used in gastrointestinal disorders. The trend of usage in Malaysia has changed from predominantly H2RA to PPI from 2007 to 2008, 3.46 versus 2.87 and 2.99 versus 3.24 DDD (Defined Daily Dose)/1000 population/day respectively. This raises concerns as PPI overutilization amounts to higher cost expenditure and are associated with various untoward consequences such as Clostridium difficile-associated diarrhea, pneumonia, and osteoporosis.
Objectives: To evaluate the indication of acid suppression therapy (AST) and to look for predictors associated with the prophylactic use of PPI as compared to H2RA.
Methods: Data collection was conducted via a standardized surveillance form over a 2-month period in the general medical wards of Sarawak General Hospital. All patients who received at least one dose of PPI or H2RA in any dosage form were included in the study. Appropriateness of prophylaxis was determined using current available guidelines. Selected risk factors were analysed using simple logistic regression to look for predictors associated with the choice of PPI in prophylactic AST.
Results: Out of 212 cases in the present cohort, about three quarters (75.5%, n=160) of acid suppressants were given as prophylaxis. Over half of these did not have appropriate indications for prophylactic AST (58.1%, n=93). Among all cases given prophylactic AST, 75.0% (n=120) of them were given PPI. Renal insufficiency was identified as the only predictor associated with the use of prophylactic PPI in preference to H2RA (OR=2.86, 95%CI 1.21:6.72, p=0.011).
Conclusion: Inappropriate prophylactic AST is a major concern and may even be underestimated due to the lack of appropriate guidelines. More data is required to guide the selection between PPI and H2RA, specifically the more cost-effective use of H2RA in patients with lower gastrointestinal risk or in whom PPI has no clear advantage.
2. Australian Government Department of Health and Ageing. Australian Statistics on Medicines 2004-2008.
3. Nordic Medico Statistical Committee. Medicines Consumption in the Nordic Countries 2004-2008. Copenhagen 2009.
4. Gisbert JP, Gonzalez L, Calvet X, Roque M, Gabriel R, Pajares JM. Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleeding peptic ulcer. Aliment Pharmacol Ther. 2001;15(7):917-926.
5. Malaysian Statistics on Medicine 2005-2008. Pharmaceutical Services Division and the Clinical Research Centre. Ministry of Health Malaysia.
6. Nardino RJ, Vender RJ, Herbert PN. Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol. 2000;95(11):3118-3122.
7. Naunton M, Peterson GM, Bleasel MD. Overuse of proton pump inhibitors. J Clin Pharm Ther. 2000;25(5):333-340.
8. Grant K, Al-Adhami N, Tordoff J, Livesey J, Barbezat G, Reith D. Continuation of proton pump inhibitors from hospital to community. Pharm World Sci. 2006;28(4):189-193.
9. Parente F, Cucino C, Gallus S, Bargiggia S, Greco S, Pastore L, Bianchi Porro G. Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: a 1-month survey. Aliment Pharmacol Ther. 2003;17(12):1503-1506.
10. Mat Saad AZ, Collins N, Lobo MM, O'Connor HJ. Proton pump inhibitors: a survey of prescribing in an Irish general hospital. Int J Clin Pract. 2005;59(1):31-34.
11. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk in overutilization of proton pump inhibitors. Am J Gastroenterol. 2009;104(Suppl 2):S27-S32. doi: 10.1038/ajg.2009.49
12. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. 1999;56(4):347-379.
13. Alhazzani W, Alenezi F, Jaeschke RZ, Moayyedi P, Cook DJ. Proton pump inhibitors versus histamine-2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2013;41(3):693-705. doi: 10.1097/CCM.0b013e3182758734
14. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af
15. Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FK, Furberg CD, Johnson DA, Mahaffey KW, Quigley EM; American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2008;118(18):1894-1909. doi: 10.1161/CIRCULATIONAHA.108.191087
16. Wang WH, Huang JQ, Zheng GF, Xia Harry HX, Wong WM, Lam SK, Wong Benjamin CY. Head-to-head comparison of H2-receptor antagonists and proton pump inhibitors in the treatment of erosive esophagitis: a meta-analysis. World J Gastroenterol. 2005;11(26):4067-4077.
17. Pongprasobchai S, Kridkratoke S, Nopmaneejumruslers C. Proton pump inhibitors for the prevention of stress related mucosal disease in critically ill patients: a meta analysis. J Med Assoc Thai. 2009;92(5):632-637.
18. Lin PC, Chang CH, Hsu PI, Tseng PL, Huang YB. The efficacy and safety of proton pump inhibitors vs histamine 2 receptor antagonists for stress ulcer bleeding pro phylaxis among critical care patients: a meta analysis. Crit Care Med. 2010;38(4):1197-1205. doi: 10.1097/CCM.0b013e3181d69ccf
19. Gupta R, , Garg P, Kottoor R, Munoz JC, Jamal MM, Lambiase LR, Vega KJ. Overuse of acid suppression therapy in hospitalized patients. South Med J. 2010;103(3):207-211. doi: 10.1097/SMJ.0b013e3181ce0e7a
20. Strid H, Simren M, Johansson AC, Svedlund J, Samuelsson O, Bjornsson ES. The prevalence of gastrointestinal symptoms in patients with chronic renal failure is increased and associated with impaired psychological general well‐being. Nephrol Dial Transplant. 2002;17(8):1434-1439.
21. Strid H, Simren M, Bjornsson ES. Overuse of acid suppressant drugs in patients with chronic renal failure. Nephrol Dial Transplant. 2003;18(3):570-575.
22. Ala‐Kaila K. Upper gastrointestinal findings in chronic renal failure. Scand J Gastroenterol. 1987;22(3):372-376.
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