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CRITICAL CARE

Proton Pump Inhibitor Formulary Considerations in the Acutely Ill Part 2: Clinical Efficacy, Safety, and Economics

Associate Professor, School of Pharmacy, Northeastern University; Clinical Pharmacist, Medical Intensive Care Unit, Tufts–New England Medical Center, Boston, MA

Lynda S Welage, PharmD FCCP

Professor of Clinical Sciences, and Associate Dean for Academic Affairs, College of Pharmacy, University of Michigan, Ann Arbor, MI

Keith M Olsen, PharmD FCCP FCCM

Professor, College of Pharmacy, University of Nebraska, Omaha, NE

Reprints: Dr. Devlin, Northeastern University School of Pharmacy, 360 Huntington Ave., Mugar Bldg. #206, Boston, MA 02115-5000, fax 617/373-7655, j.devlin{at}neu.edu

OBJECTIVE: To review, using an evidence-based approach, the clinical efficacy, safety, and cost-effectiveness of proton pump inhibitors (PPIs) for treatment of common acid peptic disorders in the acutely ill and provide clinicians with guidance when making hospital formulary decisions with this class of agents.

DATA SOURCES: MEDLINE (1966–May 2005) and the Cochrane Library databases were searched using the key words proton pump inhibitor, acid suppression, peptic ulcer disease, gastrointestinal bleeding, stress ulcer prophylaxis, critical care, safety, and cost-effectiveness. Bibliographies of cited references were reviewed, and a manual search of abstracts from recent gastroenterology, critical care, and surgery scientific meetings was completed.

STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated, and all information deemed relevant was included for this review.

DATA SYNTHESIS: PPIs have become a mainstay for acute acid suppression in hospitalized patients. Various commercially available PPI products are available either enterally or parenterally for administration to patients unable to swallow a tablet or capsule. The results of studies comparing the clinical efficacy of different PPI dosage forms and routes of administration, safety considerations, and cost-effectiveness analyses are among the factors to consider when making formulary decisions for this class of drugs.

CONCLUSIONS: While the introduction of new PPI products has expanded the therapeutic options for acid suppression in acutely ill patients, a number of unresolved questions remain surrounding the interchangeability of these products, the clinical significance of one PPI formulation over the other, and how oral/enteral therapy should be used as step-down therapy after parenteral therapy.

Key Words: proton pump inhibitors: esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole; stress ulcer prophylaxis

Published Online, October 4, 2005. www.theannals.com, DOI 10.1345/aph.1G176

THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-05-031-H01