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I’m more on the ambulatory side of pharmacy, but often see big mistakes when it comes to determining how long we should do GI prophylaxis.
GI prophylaxis is adding a medication to protect the stomach (and GI tract) from other medications or conditions that may cause GI distress of injury. Classic medications used for GI prophylaxis include adding an H2 blocker (i.e. famotidine) or a PPI (i.e. omeprazole).
The two most common examples of medications that might necessitate GI prophylaxis are oral corticosteroids (usually prednisone) and NSAIDs. The issue that I have with GI prophylaxis is that it rarely gets reassessed.
A 72 year old female has a history of CHF, CKD, and osteoarthritis. She has been experiencing an increase in symptoms of her osteoarthritis and is put on ibuprofen 400 mg three times daily. Since initiating the ibuprofen, she has begun to experience GI distress. The ibuprofen has been beneficial for her pain, so instead of switching the ibuprofen to acetaminophen, her provider places her omeprazole 20 mg daily.
Over time, her CKD and CHF continue progressing. She has a nephrology consult and the nephrologist recommends avoiding the ibuprofen. Ibuprofen gets changed to acetaminophen (which maybe it should’ve been trialed in the first place). What gets left is the indefinite omeprazole for GI prophylaxis which often turns into a magical diagnosis of GERD at some point in the patient’s life.
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I have seen this for many years. A PPI is started during a hospital stay for stress ulcer prophylaxis and continued at discharge. Many times the PCP is reluctant to discontinue a medication that he/she did not start. Patient winds up on a PPI indefinitely.
Thank you! It is so imortant to talk about this issue! Besides, it is very hard to stop PPIs as often stopping them results in rebound…so the awarness must be risen to not starting them in the first place…
Thanks for sharing!
As pharmacists we can continue to make evidenced based therapeutic interventions that improve patient care and outcomes. I understand the rational for providing GI prophylaxis for a patient using a NSAID. I would first assess whether the patient would be treated with the ibuprofen for the short-term vs. long-term. Ibuprofen is associated with a lower risk of gastric ulcers vs. other NSAIDs. However, given the patient’s side effects I can understand the addition of the PPI also in the short-term.
I agree that the use of acetaminophen would have been a better choice from the start. The patient has CHF and CKD which are comorbidites that associated with negative health outcomes with the use of an NSAID. Specifically negative cardiovascular and renal outcomes are associated with NSAID use. Also, acetaminophen has similar efficacy for treatment of osteoarthritis.
The updated BEERs criteria also does not recommend the use of PPI due to risks including osteoporosis. Moreover, there is new evidence that the use of PPI are associated with renal dysfunction.
Overall, the ibuprofen was not the best choice. It lead to a medication related problem (adverse drug event) and addition of another medication (you can argue-unnecessary medication) for the PPI. If the PPI continues then it is definitely an unnecessary medication. Given that you practice in the ambulatory care setting you have the opportunity to get a medication history on all patients taking PPIs and determine who originally prescribed the medication and what was the original indication.