when would u prescribe a hospitalized pt PPI vs ranitidine?

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[jdh71]

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haha - when it's formulary. every pt at my institution get pantoprazole

 

[BlackNDecker]

Possibly if concerned about interactions with other drugs (i.e. metabolism of Warfarin, Phenytoin, Ativan, etc.)? Though I can't recall ever prescribing a H2 receptor blocker in the hospital...

 

[gutonc]

If all you're trying to do is answer the question on ICU rounds "what are you doing for GI prophylaxis?" then prescribe an H2B. Or, if the pt came in on that and it was working, no sense messing w/ success.

If, on the other hand, you're trying to treat a primary upper GI issue and severe reflux or a bleed is the (or an) issue, then a PPI is the way to go. And there's no data to support continuous infusion PPIs over BID IV PPIs in UGIB cases (unless of course you're a drug rep and by "data," you mean "boat payment") so go with BID and save your patient (or more likely, your hospital) $400/day w/ a single, simple order.

One other thing to keep in mind is that, regardless of what your hospital has on formulary (which they're likely getting for about $0.01/PO dose regardless of the market price), there's no difference in efficacy in PPIs so choose the generic one (omeprazole) on discharge.

 

[MR1]

If I remember correct, GI stress prophylaxis is really only indicated in the ICU. I don't remember any data showing it helping floor patients. Obviously someone correct me if I am wrong on this, but probably like most hospitals everyone including the observational admits got PPI it seemed. Oh and I always loved the IV PPI, of course it has it's indications with an UGIB, but to give it to someone on the floor just b\c they are NPO??

 

[Lasclalo]

I also recently learned that there is a fairly under appreciated association of PPis with C. Diff. The proposed mechanism-- with some support in animal models-- is that the reduced pH of the stomach has antimicrobial properties (especially with regard to the tough c. dif spores).

These authors found an OR of 2.75 (95%CI: 1.68-4.52) for risk of developing c. diff colitis with the use of PPIs.

Jayatilaka S, Shakov R, Eddi R, Bakaj G, Baddoura WJ, DeBari VA.
Ann Clin Lab Sci. 2007 Summer;37(3):241-7.

Makes you wonder, as the jdh71 noted, why every patient in the hospital is on a PPi (it's the same at my institution).

 

[Adcadet]

If I remember correct, GI stress prophylaxis is really only indicated in the ICU. I don't remember any data showing it helping floor patients. Obviously someone correct me if I am wrong on this, but probably like most hospitals everyone including the observational admits got PPI it seemed. Oh and I always loved the IV PPI, of course it has it's indications with an UGIB, but to give it to someone on the floor just b\c they are NPO??

Unless I have concerns about absorption, I'll give pills to NPO patients. At my institution, NPO=NPO except meds unless you specify otherwise. My hospital's PPI is now Omeprazole, which I love because if along the way we decide the patient needs a home-going PPI and they've done fine on Omeprazole, they can just continue with it at home in OTC form.

Those on higher dose steroids should get acid therapy (and TMP/SMX for PCP prophylaxis).

Folks with significant burns should get acid therapy, although I honestly haven't seen a burn patient since my surgery rotation in medical school.

If I recall, there's somebody (staff) at my hospital who will use Cimetadine to inhibit one of the P450's to raise some drug concentration. Not sure which.

And finally, some H2 antagonists are used for allergic issues - somebody who's allergic to bees and gets stung, and those who really need IV contrast but have a known allergy. I have no idea what the evidence is and I seriously wonder how much extra good it does on top of steroids, a selective H1 antagonist, and Montelukast. But if it's my airway, I'd like an H2 antagonist.

 

[souljah1]

Most of the ICU literature was done with H2 blockers and we use ranitidine for most GI ppx in our MICU. Prophylaxis with a PPI has little evidence to support its practice. If someone has GERD or an upper GIB then starting someone on a PPI is not necessarily prophylaxis.

Many attendings teach that use of PPI's might not only lead to more Cdif but also may increase the risk of an aspiration of gastric contents transitioning from pneumonitis to aspiration pneumonia for a similar reason.

I notice that many of my co-residents start a PPI on every one who comes through the door - and many patients wind up discharged on them for no apparent reason. I'm personally a minimalist. I give folks on high dose prednisone/solumedrol PPIs for ppx and most of my ICU patients are prescribed ranitidine. Occasionally, a coagulopathic liver patient who has known portal hypertensive gastropathy will get something as well. Other than that, I don't prescribe H2 blockers or PPIs unless someone has reflux or dyspepsia.

 

[BlackNDecker]

When would u prescribe a hospitalized pt a PPI vs. Ranitidine?

I've been mulling over this topic for several days now, especially after having a patient on long-term prophylaxis with PPI complain of late-afternoon reflux. So in this particular instance, if forced to choose between the two, a histamine receptor antagonist would be the better choice due to its more rapid onset of action.

However, a quick discussion with the nurse revealed that the patient was getting AM meds with breakfast. PPIs are much more effective given on an empty stomach, and since "rewriting" the order with this suggestion, I've not heard any further complaints.

The pharmokinetics of PPIs make them better suited for long-term prevention of heartburn rather than acute symptoms. Complete heartburn relief occurs in ~ 30% of individuals following their first dose of PPI. H2A's may be better suited to the treatment of intermittent symptoms of heartburn.

 

[dragonfly99]

Gutondoc got it right.
You should only rx GI prophylaxis in patients where it is medically indicated, so have to learn the medical indications (many or all of them are mentioned in this thread). If a patient isn't NPO, doesn't have h/o GERD or GI ulcers and isn't burn/trauma, taking oral steroids, etc. then he doesn't necessarily need GI prophylaxis.

 

[gutonc]

If a patient isn't NPO...

>24h NPO is my personal rule. Sometimes accidentally gets prolonged to 48h but seriously, are you going to have an acute stress ulcer from 2d of not eating if you didn't already have (or were iatrogenically given) a predisposing condition unless you get a PPI? Doubtful. That said, anyone who is NPO for anything other than a procedure gets prophylaxis.

 

[carrigallen]

Those on higher dose steroids should get acid therapy (and TMP/SMX for PCP prophylaxis).

I think probably no need to start bactrim until they have been on high dose steroids for >7-14 days and even then I'm not sure if there is good evidence.