Emergency Physicians May Be Overprescribing PPIs

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Key clinical point: ED physicians may soon be getting an earful from advocates of the ABIM’s Choosing Wisely Program in light of new evidence of ED overprescribing of proton pump inhibitors.

Major finding: In 2001, 3% of adult visits to U.S. EDs included a prescription for a PPI. By 2010, this rate had more than doubled to 7.2%.

Data source: This was a retrospective analysis of data from the annual National Hospital Ambulatory Care Survey for 2001-2010, which provides a detailed snapshot of ED visits across the United States.

Disclosures: The presenter reported having no financial conflicts regarding his study, which was supported by institutional funds.


AT SAEM 2014


DALLAS – The frequency at which U.S. emergency department physicians prescribed proton pump inhibitors more than doubled during 2001-2010, despite mounting safety concerns surrounding this class of medications.

"More education may be needed to ensure ED providers are familiar with the appropriate indications for PPI use. The big thing that I’m hoping will be taken away from this study is that because of the increase in prescribing PPIs [proton pump inhibitors] and the concerns about safety, that we’re going to be more vigilant in educating ourselves and each other about appropriate use of these medications," Dr. Maryann Mazer-Amirshahi said at the annual meeting of the Society for Academic Emergency Medicine.

Overprescribing of PPIs has been well documented in primary care offices, gastroenterology clinics, and inpatient settings. Up until now, however, prescribing patterns in the ED haven’t been well documented. The Centers for Disease Control and Prevention’s annual National Hospital Ambulatory Care Survey provided an opportunity to do so via a weighted nationally representative sample of ED visits, explained Dr. Mazer-Amirshahi of Children’s National Medical Center, Washington.

She presented a retrospective analysis of survey data for the years 2001-2010, during which the annual number of adult ED visits climbed from 20.1 million to 28.3 million. Meanwhile, PPI prescribing increased from 3% of adult patients in 2001 to 7.2% in 2010.

"I think that’s pretty significant when you’re talking about more than 7% of 28 million ED visits every year," she commented.

While PPI prescribing more than doubled during the study years, the use of alternative medications declined. Histamine2 blocker use dropped from 6.8% in 2001 to 5.7% in 2010, while the use of antacids decreased from 7.2% to 5.5%.

PPI prescribing rose in EDs in hospitals of all types: nonprofit, for-profit, and government. It increased in all regions of the country and across all payer types, including self-payment. Of note, the number of ED prescriptions increased to a greater extent in teaching hospitals, with a 276% increase, as compared with a 118% increase in nonteaching hospitals. Prescribing of PPIs by attending ED physicians climbed by 122%, by 185% by emergency medicine residents, and by 345% by mid-level providers.

In 2001, 3.3% of ED patients aged 65 years or older received a PPI. By 2010, this figure had climbed to 6.8%, a 104% increase. This trend is of particular concern because the elderly are the group at highest risk of PPI-related adverse events, including osteoporotic fractures, hypomagnesemia, drug-drug interactions, stent thrombosis, Clostridium difficile colitis, and community acquired pneumonia, Dr. Mazer-Amirshahi noted.

Roughly half of patients who got a PPI in the ED during the study years did not have a clear gastrointestinal complaint as the primary reason for their visit, suggesting that much of the ED prescribing of PPIs was not for an approved indication, she continued.

Dr. Mazer-Amirshahi observed that PPI prescribing has received special attention in the Choosing Wisely Program sponsored by the American Board of Internal Medicine, which recommends conducting a drug regimen review before prescribing a PPI in order to avoid drug-drug interactions. It’s also important to know whether a patient has osteoporosis before prescribing a PPI for longer than a few weeks. And there are additional reasons to think twice before prescribing a PPI in the ED.

"In the ED, we generally want to give our patients rapid symptom relief. PPIs have a delayed onset of action. They take 12-24 hours to take effect, so in many situations we might be better off giving an H2 blocker, which acts faster and is less costly," she said.

Dr. Mazer-Amirshahi reported having no financial conflicts regarding her study.

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