PPIs started for stress ulcer prophylaxis in critically ill patients often continued after ICU, hospital discharge

A study at one U.S. academic medical center found that nearly half of patients who started proton-pump inhibitors (PPIs) in the ICU without an indication for outpatient use continued them after transfer to the floor, and 27% continued them after discharge.

More than a quarter of patients who started proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in the ICU without a long-term indication continued them after discharge in a recent study.

Researchers looked at the prevalence and risk factors for inappropriate discharge on PPI therapy started in the ICU for stress ulcer prophylaxis in a cohort of adults who were admitted to one of nine ICUs at an academic medical center in New York City from 2014 through 2018 and survived to discharge. They used diagnoses and relevant ICD codes to classify PPIs as indicated or not and excluded patients who had an appropriate long-term PPI indication. The primary outcome was inappropriate continuation of PPI therapy at the time of hospital discharge, which was classified based on the discharge medication reconciliation note. Results were published online on Dec. 9 by Mayo Clinic Proceedings.

Of 24,751 patients admitted to an ICU, 4,127 (17%) started treatment with a new PPI, with 2,467 (60%) lacking a long-term PPI indication. Of these, 1,122 (45%) patients continued PPI therapy after transfer to the floor and 668 (27%) were discharged on PPI therapy. In a multivariable analysis, risk factors for inappropriate discharge on PPI therapy included upper endoscopy (adjusted odds ratio [OR], 1.70; 95% CI, 1.08 to 2.66), admission to surgical versus medical ICU (adjusted OR, 2.03; 95% CI, 1.32 to 3.10), and discharge to a nursing home or rehabilitation facility (adjusted ORs, 1.43 [95% CI, 1.04 to 1.96] and 2.29 [95% CI, 1.62 to 3.24], respectively).

Limitations of the study included its single-center design and that only a small number of patients had outpatient follow-up records available, the authors noted. They added that using ORs in the risk factor analysis can overestimate the risk as the outcome of interest becomes more common.

The results indicated that 16% of patients, or about 1 in every 6, who start PPIs in the ICU are inappropriately continued on them at discharge, the authors noted. “Encouragingly, some ICU types, for example, cardiac specialty ICUs, started more PPI therapy but were also better at PPI deprescribing,” they wrote. “Future quality improvement initiatives can be designed based on these data to reduce the rate of inappropriate PPI prescriptions after ICU stay.”