Hospital Pharmacy - February 2018 - 65
Wahking et al
time.12 Therefore, these patients may produce more gastric
acid than those patients who eat a diet relatively low in fat,
worsening symptom reoccurrence in obese patients. Larger
studies will be necessary to fully study this relationship, but
it is possible that some obese patients may benefit from
scheduled inpatient AST therapy or a PPI taper, particularly
if they have other risk factors, such as longer LOS.
While there was a trend toward higher outpatient PPI dose
as a risk factor for unsuccessful PPI discontinuation during
inpatient stay, this finding was not statistically significant. As
higher doses and areas under the curve (AUC) lead to a greater
acid-reducing effect, it is possible that patients with a higher
outpatient PPI dose are more sensitive to rebound hyperacidity, thus decreasing the chance of successful discontinuation.32
Therefore, the abrupt withdrawal strategy in our study may not
be the most effective approach to these patients. Perhaps a
step-down approach, similar to that described by other successful studies, may be more appropriate for patients on relatively high PPI doses (greater than 40 mg per day).14,15
The outpatient component of the PPI stewardship program was also successful, resulting in a 57.1% discontinuation rate and an 81.8% dose de-escalation rate in eligible
patients. The reasons for our relatively high success rates are
likely multifactorial. First, clear criteria were established by
the stewardship team regarding appropriate indications for
PPI continuation. These criteria allowed for the targeting of
patients with weaker PPI indications and therefore, stronger
likelihoods for tolerating PPI discontinuation. In addition,
discharge counseling by medication reconciliation pharmacists likely enhanced positive outcomes. Patients were educated about the potential adverse effects of PPIs, the reasons
for recommended discontinuation, and the possibility of, and
strategies to combat, rebound hyperacidity. Furthermore, as
there appears to be a placebo effect in some patients with
GERD, the knowledge that they did not require PPIs while
hospitalized may have encouraged some patients in their
efforts to discontinue therapy entirely.33
Our discontinuation rates are consistent with the findings
of previous studies demonstrating PPI discontinuation rates
of 14% to 64%.11 Moreover, our study's success rate of
57.1% is at the high end of the observed range, despite the
fact that a PPI taper, which generally seems to produce the
greatest success, was not used. The greatest commonalities
between our program and other successful PPI stewardship
programs include implementation of thorough patient counseling and provision of replacement "as needed" AST. Murie
et al implemented a nurse-led dyspepsia clinic in which
patients were counseled on their condition and lifestyle
modifications to decrease symptoms of dyspepsia and were
provided with alternative medications for the treatment of
rebound hyperacidity.34 At 3 months, the researchers documented a 59.4% success rate for PPI discontinuation and a
29.7% success rate for dose de-escalations. Conversely,
Krol et al mailed educational letters to patients suggesting
they discontinue or reduce their PPI use, which yielded a
65
lower success rate (24%), compared with Murie et al, which
may be attributed to a lack of face-to-face counseling, as
well as lack of alternative AST therapies provided.13 Thus,
our study appears to confirm the Murie et al conclusion that
patient education and measures to counter rebound hyperacidity (such as "as needed" AST or PPI step-down therapy)
are essential components to a successful PPI stewardship
program.
Not only did the PPI stewardship program effectively discontinue and reduce doses of PPIs, but complications related
to the actions of the stewardship team appear minimal. Of the
patients who underwent an outpatient PPI intervention, only
1 case of reflux esophagitis was reported 2 months after discontinuation. Therefore, the interventions of the PPI stewardship program appear safe, although it is important to note
that we cannot rule out the possibility that complications
may develop in the future, as it may take longer than 3
months to develop an acid-related complication.35 However,
the risk of any future acid-related complications must be balanced with the risk of any future complications associated
with continued PPI use, including enteric infections, pneumonia, fractures, and hypomagnesemia.
There were several limitations associated with this study.
First, this was a retrospective cohort study with a relatively
homogeneous population of male veterans, conducted in
patients admitted to a medicine service at our facility. It is
possible that the results may not be generalizable to the general population or other specialty services. However, there is
no reason to believe that a similar program implemented in
other populations and with other specialty services would
not be successful, with the possible exception of the critically ill population as many require PPIs for stress ulcer prophylaxis.36 It is also possible that the 3-month follow-up
period was too short to detect all PPI resumption. Murie et al
found rates of successful discontinuation had decreased from
59.4% to 32.5% from a 3- to a 12-month follow-up, suggesting that outpatient discontinuation/de-escalation success
rates may not persist long-term.34 Thus, a longer follow-up
period may be beneficial in future studies. In addition, our
findings that BMI and longer LOS were associated with
inpatient PPI resumption will need to be confirmed with
larger studies, as our sample size was relatively small (n = 9).
Furthermore, this study was not designed to evaluate whether
the PPI stewardship program decreased complications associated with PPI overuse, such as CDI, due to the already low
rates of these events at our facility. Further studies will be
required to evaluate whether this program improves clinical
outcomes. A final study limitation is related to the fact that
PPIs are available for purchase over the counter (OTC). As
this study did not capture OTC PPI use upon discharge, the
true outpatient discontinuation rate may be lower than it
appears.
Conversely, this study exhibits a number of strengths. As
there is currently no clear consensus on the optimal strategy
to facilitate PPI deprescribing, this study demonstrates the
Table of Contents for the Digital Edition of Hospital Pharmacy - February 2018
Ed Board
TOC
Editorial
The Evolving Frontier of Digital Health: Opportunities for Pharmacists on the Horizon
Letter to the Editor
Immediate Attention Required: Another Shortage
ISMP Adverse Drug Reactions
ISMP Adverse Drug Reactions
Current FDA-Related Drug Information
Summaries of Safety Labeling Changes Approved By FDA: Boxed Warnings Highlights July-September 2017
ISMP Medication Error Report Analysis
Common Missteps With Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans
Formulary Drug Reviews
Betrixaban
Pharmaceutical Pipeline Update
Antibiotics in Development for the Treatment of Resistant Bacterial Disease
Articles
Evaluation of the Incidence of Ibuprofen Administration in Alcohol and Opioid Detoxification Patients With Concomitant Thrombocytopenia
Antimicrobial Utilization Pattern in Pediatric Patients in Tertiary Care Hospital, Eastern Ethiopia: The Need for Antimicrobial Stewardship
Acute Hepatocellular Jaundice After Dofetilide Initiation: A Case Report
Outcomes From a Pharmacist: Led Proton Pump Inhibitor Stewardship Program at a Single Institution
Corrigendum
Hospital Pharmacy - February 2018 - Cover1
Hospital Pharmacy - February 2018 - Cover2
Hospital Pharmacy - February 2018 - 1
Hospital Pharmacy - February 2018 - 2
Hospital Pharmacy - February 2018 - 3
Hospital Pharmacy - February 2018 - Ed Board
Hospital Pharmacy - February 2018 - TOC
Hospital Pharmacy - February 2018 - Editorial
Hospital Pharmacy - February 2018 - The Evolving Frontier of Digital Health: Opportunities for Pharmacists on the Horizon
Hospital Pharmacy - February 2018 - 8
Hospital Pharmacy - February 2018 - 9
Hospital Pharmacy - February 2018 - 10
Hospital Pharmacy - February 2018 - Letter to the Editor
Hospital Pharmacy - February 2018 - Immediate Attention Required: Another Shortage
Hospital Pharmacy - February 2018 - 13
Hospital Pharmacy - February 2018 - ISMP Adverse Drug Reactions
Hospital Pharmacy - February 2018 - ISMP Adverse Drug Reactions
Hospital Pharmacy - February 2018 - 16
Hospital Pharmacy - February 2018 - Current FDA-Related Drug Information
Hospital Pharmacy - February 2018 - Summaries of Safety Labeling Changes Approved By FDA: Boxed Warnings Highlights July-September 2017
Hospital Pharmacy - February 2018 - 19
Hospital Pharmacy - February 2018 - 20
Hospital Pharmacy - February 2018 - 21
Hospital Pharmacy - February 2018 - 22
Hospital Pharmacy - February 2018 - 23
Hospital Pharmacy - February 2018 - ISMP Medication Error Report Analysis
Hospital Pharmacy - February 2018 - Common Missteps With Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans
Hospital Pharmacy - February 2018 - 26
Hospital Pharmacy - February 2018 - 27
Hospital Pharmacy - February 2018 - Formulary Drug Reviews
Hospital Pharmacy - February 2018 - Betrixaban
Hospital Pharmacy - February 2018 - 30
Hospital Pharmacy - February 2018 - 31
Hospital Pharmacy - February 2018 - 32
Hospital Pharmacy - February 2018 - 33
Hospital Pharmacy - February 2018 - 34
Hospital Pharmacy - February 2018 - 35
Hospital Pharmacy - February 2018 - 36
Hospital Pharmacy - February 2018 - Pharmaceutical Pipeline Update
Hospital Pharmacy - February 2018 - Antibiotics in Development for the Treatment of Resistant Bacterial Disease
Hospital Pharmacy - February 2018 - 39
Hospital Pharmacy - February 2018 - Articles
Hospital Pharmacy - February 2018 - Evaluation of the Incidence of Ibuprofen Administration in Alcohol and Opioid Detoxification Patients With Concomitant Thrombocytopenia
Hospital Pharmacy - February 2018 - 42
Hospital Pharmacy - February 2018 - 43
Hospital Pharmacy - February 2018 - Antimicrobial Utilization Pattern in Pediatric Patients in Tertiary Care Hospital, Eastern Ethiopia: The Need for Antimicrobial Stewardship
Hospital Pharmacy - February 2018 - 45
Hospital Pharmacy - February 2018 - 46
Hospital Pharmacy - February 2018 - 47
Hospital Pharmacy - February 2018 - 48
Hospital Pharmacy - February 2018 - 49
Hospital Pharmacy - February 2018 - 50
Hospital Pharmacy - February 2018 - 51
Hospital Pharmacy - February 2018 - 52
Hospital Pharmacy - February 2018 - 53
Hospital Pharmacy - February 2018 - 54
Hospital Pharmacy - February 2018 - Acute Hepatocellular Jaundice After Dofetilide Initiation: A Case Report
Hospital Pharmacy - February 2018 - 56
Hospital Pharmacy - February 2018 - 57
Hospital Pharmacy - February 2018 - 58
Hospital Pharmacy - February 2018 - Outcomes From a Pharmacist: Led Proton Pump Inhibitor Stewardship Program at a Single Institution
Hospital Pharmacy - February 2018 - 60
Hospital Pharmacy - February 2018 - 61
Hospital Pharmacy - February 2018 - 62
Hospital Pharmacy - February 2018 - 63
Hospital Pharmacy - February 2018 - 64
Hospital Pharmacy - February 2018 - 65
Hospital Pharmacy - February 2018 - 66
Hospital Pharmacy - February 2018 - 67
Hospital Pharmacy - February 2018 - Corrigendum
Hospital Pharmacy - February 2018 - Cover3
Hospital Pharmacy - February 2018 - Cover4
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