PPI Use Often Continues After Intensive-Care Discharge Despite Lack Of Indication

Many patients started on proton pump inhibitors (PPIs) in the intensive care unit (ICU) continue on these medications after discharge, even when there's no indication for outpatient use, a U.S. study suggests.

Researchers examined data on 24,751 patients admitted to one of nine ICUs at a single large medical center from 2014 to 2018, and patients were excluded if they had an indication for long-term PPI use. Among the patients included in the study, a total of 4,127 initiated PPI treatment in the ICU.

Most of the patients who initiated PPIs in the ICU (60%) didn't have a medical indication for long-term use of the drugs. However, many people without a medical indication for long-term PPI use were still given the drugs when they were transferred from the ICU to another hospital unit (45%) and when they were discharged (27%).

ICU patients often have very complicated, sometimes lengthy hospitalizations, and the clinicians taking care of them after they leave the ICU may err on the side of continuing medications, especially if they're unsure about the circumstances in which they were started, said lead study author Dr. John Blackett of New York Presbyterian Hospital/Columbia University Irving Medical Center in New York City.

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"Providers may not realize that PPIs started for ulcer prophylaxis in the ICU were intended for short-term use," Dr. Blackett said by email. "Often, medications of borderline necessity are started during a hospitalization with the belief that an outpatient provider will sort it out at a follow up appointment after discharge."

With PPIs in particular, clinicians may consider these a benign medication with low potential for harm and no need for discontinuation even when the indication isn't clear, Dr. Blackett added.

"There is some controversy over the risks of long-term PPI use, but when there is a good indication for PPI use, like acid reflux or peptic ulcer disease, the benefits clearly outweigh the risk," Dr. Blackett said. "However, when there is no indication, even a very low risk of an adverse outcome should not be tolerated."

Researchers identified patients with inappropriate PPI use based on the discharge medical reconciliation note completed before all patients leave the hospital. They classified patients as having inappropriate PPI use unless patients had one of several indications detailed in the discharge medical reconciliation note including: ulcers, esophagitis, gastroesophageal reflux, peptic ulcer, lung transplant, or discharge treatment with medications such as NSAIDs, or antiplatelet medication with an anticoagulant.

Some of the risk factors for inappropriate PPI continuation after discharge included having an upper endoscopy (adjusted odds ratio 1.70), admission to surgical instead of medical ICU (aOR 2.03), and discharge to a rehabilitation facility (aOR 2.29) or nursing home (aOR 1.43).

One limitation of the study is that it was conducted at a single academic medical center, the study team notes in Mayo Clinic Proceedings. Another is that researchers relied on ICD codes to identify appropriate versus inappropriate PPI usage, so misclassification in some instances is possible.

There may have been indications for some patients to continue PPI use that weren't recorded, said Dr. Tom MacDonald of the University of Dundee and Ninewells Hospital & Medical School in the UK. It's also not clear to what extent continuing PPIs was harmful to patients in the study, Dr. MacDonald, who wasn't involved in the study, said by email.

"Many physicians also have a low threshold to prescribe these drugs and because they pose little risk and are inexpensive, the drivers to discontinue them are limited," Dr. MacDonald said. "Also, discontinuation often causes rebound dyspepsia so patients resist stopping them."

—Lisa Rapaport

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