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The PPI dilemma:  miracle pills The PPI dilemma:  miracle pills

The PPI dilemma: miracle pills - PowerPoint Presentation

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The PPI dilemma: miracle pills - PPT Presentation

or enemies of the state Janelle Jones Dev Jayaraman Todd C Lee Outline PPI overprescription PPI adverse effects PPI indications The PPI project and how you can help Heres the problem ID: 921387

increased ppi pain acid ppi increased acid pain risk 2011 proton retrospective meta analysis antiplatelet pump months adverse suppressive

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Slide1

The PPI dilemma: miracle pills or enemies of the state?

Janelle

Jones, Dev Jayaraman, Todd C. Lee

Slide2

Outline PPI over-prescriptionPPI adverse effectsPPI indications

The PPI project and how you can help!

Slide3

Here’s the problem…Gastrointestinal complaints are incredibly commonHeartburn

Reflux

“Indigestion”

Bloating

Slide4

And the solution?Marketed direct to consumer and physician alike

The proton pump inhibitor!

Slide5

PPI Overprescription

Slide6

PPI OverprescriptionNaunton

(2000) Retrospective study. 200

pts

on PPI- approved indications 37%. Median duration of PPI use 450 days.

Zink (2005) Retrospective. 60% on PPI without indication during hospitalization. 34% discharged on PPI. Longer length of stay predictive. At 3 months- 80% and 6 months – 50% still on PPI inappropriately.

Pham (2006) Retrospective. 29% on acid suppressive, 33% PPIs. During Admission – increased to 84% PP1. Only 10% had indication.

Slide7

Adverse effects – random PPI monograph

1

% to 10%:

CNS:

Headache (7%), dizziness (2%)

Derm

:

Rash (2%)

GI:

Abdominal pain (5%), diarrhea (4%), nausea (4%), vomiting (3%), flatulence (3%), acid regurgitation (2%), constipation (2%)

Resp

:

Upper respiratory infection (2%), cough (1%)

≤1%

(Limited to important or life-threatening; adverse event occurrence may vary based on formulation): Abdominal swelling, abnormal dreams, aggression, agitation,

agranulocytosis

, alkaline phosphatase increased, allergic reactions, alopecia, ALT increased, anaphylaxis, anemia, angina, angioedema, anorexia, anxiety, apathy, AST increased, atrophic gastritis, benign gastric polyps, bilirubin increased, blurred vision,

bradycardia

, bronchospasm, chest pain,

cholestatic

hepatitis, confusion,

creatinine

increased, depression, double vision, dry skin, epistaxis, erythema

multiforme

, esophageal candidiasis, fatigue, fecal discoloration, fever, fracture,

gastroduodenal

carcinoids, GGT increased, glycosuria,

gynecomastia

, hallucinations, hematuria, hemolytic anemia, hepatic encephalopathy, hepatic failure, hepatic necrosis, hepatitis, hepatocellular hepatitis, hyperhidrosis, hypersensitivity, hypertension, hypoglycemia,

hypomagnesemia

,

hyponatremia

, insomnia, interstitial nephritis, irritable colon, jaundice, joint pain, leg pain, leukocytosis, leukopenia, liver disease (hepatocellular,

cholestatic

, mixed), malaise, microscopic colitis, microscopic

pyuria

, mucosal atrophy (tongue), muscle cramps, muscle weakness, myalgia, nervousness, neutropenia, ocular irritation, optic atrophy, optic neuritis, optic neuropathy (anterior ischemic), osteoporosis-related fracture, pain, palpitation, pancreatitis, pancytopenia,

paresthesia

, peripheral edema,

petechiae

, pharyngeal pain, photosensitivity, proteinuria, pruritus, psychiatric disturbance,

purpura

, skin inflammation, sleep disturbance, somnolence, Stevens-Johnson syndrome, stomatitis, tachycardia, taste perversion, testicular pain, thrombocytopenia, tinnitus, toxic epidermal

necrolysis

, tremor, urinary frequency, urinary tract infection,

urticaria

, vertigo, weight gain,

xerophthalmia

,

xerostomia

Slide8

Adverse effects – the “special problems”

Dial et al. (2006) – CMAJ – cohort/case-control study- use of PPI was associated with C. diff diarrhea OR 2.7 (95%CI 1.4-5.2).

Aseeri

et al. (2008) – AJG –retrospective case control – CDAD was associated with use of PPI OR 3.6 (95%CI 1.7-8.3

)

Slide9

Continued.Chun Shing Kwok et al. (2011) – AJG – meta-analysis of 42 observational studies including 313000 patients. Association between PPI and risk of CDAD – OR 1.74 (95% CI 1.47-2.85). Concomitant PPI and

Abx

CI 1.96 (95%CI 1.03-3.70).

Slide10

Other “special problems”: fracturesFracture risk-

Yu et al. (2011) – Am J med – meta-analysis of 11 international studies including 1,084 560 patients.

Hip # RR 1.30 (95%CI 1.19-1.43)

No increase with H2 blockers

Slide11

Other harmful associations in literature?PneumoniaHospital Acquired Pneumonia

Functional decline in elderly

Falls in elderly

All cause mortality post-discharge

B12 deficiency

There are more…

Slide12

Are PPIs all bad?Of course not

One needs to balance the therapeutic benefit with the potential risks

For certain indications the evidence is in favor of using these medications

Slide13

IndicationsUlcer

with documented bleed or symptoms within 3 months

Pathological

secretatory

conditions (i.e.

Zollinger

-Ellison)

GERD or severe indigestion with exacerbation within 3 months and non-responsive to H2 blocker

Erosive esophagitis

Helicobacter therapyDual Antiplatelet therapyAntiplatelet and Anticoagultion

Antiplatelet and previous complicated ulcer

Antiplatelet/NSAID and more than one of: Age >60, Corticosteroids, Previous Uncomplicated Ulcer,

Concomittant

NSAID/Antiplatelet

Slide14

PPI AuditWhat can YOU do to help this project?

Find out if your patient is on a PPI and ask them WHY.

Discuss the reasons why stopping the PPI is important if there is no

ongoing indication.

Enter the patient in the web tool (the link was given to them here)

Ensure the patient receives a copy of the letter

to community MD

if you stop the therapy

Slide15

Our success story so far- the data.This slide would be updated monthly during the intervention

Slide16

Thank you!

Slide17

References.M.

Naunton

, G. M. Peterson, M. D.

Bleasel

(2000) Overuse of proton pump inhibitors. J

Clin

Pharm

Ther

. 2000 October; 25(5): 333–340

.Zink D.A., Pohlman M., Barnes M., Cannon M.E. (2005) Long-term use of acid suppression started inappropriately during hospitalization. Aliment

Pharmacol

Ther

21: 1203–1209

.

Pham C.Q.D., Regal R.E.,

Bostwick

T.R.,

Knauf

K.S. (2006) Acid suppressive therapy use on an inpatient internal medicine service. Ann

Pharmacother

40: 1261–1266

.

Dial S., Delaney J.A.C.,

Barkun

A.N.,

Suissa

S. (2005) Use of gastric acid-suppressive agents and the risk of community-acquired

Clostridium

difficile

-associated disease. JAMA 294:

2989–2995.

Aseeri

M., Schroeder T., Kramer J.,

Zackula

R. (2008) Gastric acid suppression by proton pump inhibitors as a risk factor for

Clostridium-

difficile

-associated diarrhea in hospitalized patients. Am J

Gastroenterol

103: 2308–2313

.

Chun

Shing Kwok et al

. (2011)

Risk

of Clostridium

difficile

Infection With Acid Suppressing Drugs and Antibiotics:

Meta-Analysis.

The American Journal of

Gastroenterology

107 (7), 2012,

p.1011

Yu EW, Bauer SR, Bain PA, Bauer DC

.(2011)

Proton pump inhibitors and risk of fractures: a meta-analysis of 11 international

studies

Am J Med. 2011 Jun;124(6):519-26

.