International Journal of Clinical Pharmacy

, Volume 37, Issue 6, pp 1152–1161 | Cite as

The use of proton pump inhibitors in an Italian hospital: focus on oncologic and critical non-ICU patients

  • Maria MeliEmail author
  • Maria Pia Raffa
  • Renato Malta
  • Ilaria Morreale
  • Luigi Aprea
  • Natale D’Alessandro
Research Article


Background Proton pump inhibitors (PPIs) are among the most misused drugs both at the community and hospital level. Recently, possible risks have been underscored, suggesting the importance of limiting PPI use to proven indications. Objective To survey the appropriateness of PPI use in a University hospital in Italy. Setting Azienda Ospedaliera Universitaria Policlinico ‘P. Giaccone’, in Palermo, Italy. Method A one day-observational study, reviewing patients’ medical records to identify treatments with PPIs and the indications for their use. After discharge, a subgroup of the cohort was followed up to assess the continuation of therapy at home. Appropriateness was evaluated according to the indications stated in the official product information sheet and supported by the AIFA notes. Main outcome measure Prevalence and appropriateness of PPI use in the hospital and after discharge. Results In the index day 62.9 % of 343 evaluable patients received a PPI. In only 29.1 % of these, the treatment could be considered appropriate. The most frequent reasons for inappropriate treatment were stress ulcer prophylaxis in low risk patients and unwarranted gastro-protection in drug treated patients. 30.9 % of patients received PPIs for uncertain indications: of these, 25.7 % were “critical” patients admitted in non-ICU wards. Furthermore, as much as 88.2 % of anticancer drug treated patients received PPIs as gastroprotective agents. At discharge 48.6 % of patients received a prescription to continue PPI therapy at home and 75.9 % of the 83 followed up patients were found to be still taking these drugs after on average 3 months from discharge. Conclusion This study confirms a high proportion of inappropriate PPI therapy into the hospital that translates in a prolonged unnecessary administration in the community setting. Further studies are needed to assess the cost-effectiveness of PPI therapy in subgroups of patients at moderate risk for gastric complications to optimize current guidelines.


Drug utilization Hospital Italy Proton pump inhibitors Therapeutic appropriateness 



The authors thank the physicians of the Policlinico “P. Giaccone” of Palermo Doctors: Alessandra Adamo, Salvo Asciutto, Vincenza Alonge, Mario Belvedere, Sergio Calamia, Giuseppe Cannizzaro, Maria Cappello, Egle Corrado, Bianca Maria Cudia, Francesco D’Arpa, Domenico Di Raimondo, Luisa Falletta, Angelo Ferrante, Fabio Fulfaro, Girolamo Geraci, Vincenzo Geraci, Fabio Giacalone, Lydia Giannitrapani, Antonella Giugno, Maria Pia Imbergamo, Egle Incalcaterra, Nicola Lo Biundo, Francesco Lombardo, Filippo Longo, Carla Maione, Pasquale Mansueto, Antonietta Matina, Gaetano Morreale, Ida Muratori, Mario Napoli, Giuseppe Pistone, Giuseppe Profita, Simona Raso, Giovanni Ruvolo, Francesco Vaccaro, Giorgia Virzì, Giovanni Zabbia, Carmela Zarino for their support in reviewing and evaluating the clinical documentation of patients.


No funding was received for this study.

Conflicts of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Morini S, Zullo A, Oliveti D, Chirlatti A, Marmo R, Chiuri DA, et al. A very high rate of inappropriate use of gastroprotection for nonsteroidal anti-infiammatory drug therapy in primary care: a cross-sectional study. J Clin Gastroenterol. 2011;45:780–4.CrossRefPubMedGoogle Scholar
  2. 2.
    Cahir C, Fahey T, Tilson L, Teljeur C, Bennet K. Proton pump inhibitors: potential cost reductions by applying prescribing guidelines. BMC Health Serv Res. 2012;12:408. doi: 10.1186/1472-6963-12-408.PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Gingold AR, Narasimhan G, Augello S, Clain DJ. The prevalence of proton pump inhibitor use in hospitalized patients. Pract Gastroenterol. 2006;30(5):24–34.Google Scholar
  4. 4.
    Craig DGN, Thimappa R, Anand V, Sebastian S. Inappropriate utilization of intravenous proton pump inhibitors in hospital practice. A prospective study of the extent of the problem and predictive factors. Q J Med. 2010;103:327–35.CrossRefGoogle Scholar
  5. 5.
    Haroon M, Yasin F, Gardezi SKM, Adeeb F, Walker F. Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study. J R Soc Med Short Rep. 2013;4:36. doi: 10.1177/2042533313497183.Google Scholar
  6. 6.
    Eid SM, Boueiz A, Paranji S, Mativo C, Landis R, Abougergi MS. Patterns and predictors of proton pump inhibitor overuse among academic and non-academic hospitalists. Intern Med. 2010;49:2561–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Ther Adv Gastroenterol. 2012;5:219–32.CrossRefGoogle Scholar
  8. 8.
    Agenzia Italiana del Farmaco. Note AIFA 2009 Una guida per l’uso appropriato dei farmaci. Bollettino Informazione Farmaci. 2009;16(5–6):193–7.Google Scholar
  9. 9.
    Agenzia Italiana del Farmaco. Note AIFA 2009 Una guida per l’uso appropriato dei farmaci. Bollettino Informazione Farmaci. 2009;16(5–6):220–2.Google Scholar
  10. 10.
    Parente F, Cucino C, Gallus S, Bargiggia S, Greco S, Pastore L. Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: a 1-month survey. Aliment Pharmacol Ther. 2003;17:1503–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Chia CT, Lim WP, Vu CK. Inappropriate use of proton pump inhibitors in a local setting. Singap Med J. 2014;55(7):363–6.CrossRefGoogle Scholar
  12. 12.
    Gupta R, Garg P, Kottoor R, Munoz JC, Jamal MM, Lambiase LR, et al. Overuse of acid suppression therapy in hospitalized patients. South Med J. 2010;103(3):207–11.CrossRefPubMedGoogle Scholar
  13. 13.
    Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006;101:2200–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Nasser SC, Nassif JG, Dimassi HI. Clinical and cost impact of intravenous proton pump inhibitor use in non-ICU patients. World J Gastroenterol. 2010;16:982–6.PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Sartori S, Trevisani L, Nielsen I, Tassinari D, Panzini I, Abbasciano V. Randomized trial of omeprazole or ranitidine versus placebo in the prevention of chemotherapy-induced gastroduodenal injury. J Clin Oncol. 2000;18(3):463–7.PubMedGoogle Scholar
  16. 16.
    Grant K, Al-Adhami N, Tordoff J, Livesey J, Barbezat G, Reith D. Continuation of proton pump inhibitors from hospital to community. Pharm World Sci. 2006;28:189–93.CrossRefPubMedGoogle Scholar
  17. 17.
    Ahrens D, Chenot JF, Behrens G, Grimmsmann T, Kochen M. Appropriateness of treatment recommendations for PPI in hospital discharge letters. Eur J Clin Pharmacol. 2010;66:1265–71.PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Ntaios G, Chatzinikolaou A, Kaiafa G, Savopoulos C, Hatzitolios A, Karamitsos D. Evaluation of use of proton pump inhibitors in Greece. Eur J Intern Med. 2009;20:171–3.CrossRefPubMedGoogle Scholar
  19. 19.
    Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301:2120–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Tleyjeh IM, Abdulhak AAB, Riaz M, Alasmari FA, Garbati MA, AlGhamdi M, et al. Association between proton pump inhibitor therapy and Clostridium difficile infection: a contemporary systematic rewiew and meta-analysis. PLoS One. 2012;7:e50836. doi: 10.1371/journal.pone.0050836.PubMedCentralCrossRefPubMedGoogle Scholar
  21. 21.
    Yang YX, Metz DC. Safety of proton pump inhibitor exposure. Gastroenterology. 2010;139:1115–27.CrossRefPubMedGoogle Scholar
  22. 22.
    Wedemeyer R-S, Blume H. Pharmacokinetic drug interaction profiles of proton pump inhibitors: an update. Drug Saf. 2014;37:201–11.PubMedCentralCrossRefPubMedGoogle Scholar
  23. 23.
    Meli M, Malta R, Aprea L, Pasquale A, La Seta C, Di Rosa S, et al. Proton pump inhibitor use in a university teaching hospital. Ital J Med. 2012;6:202–9.CrossRefGoogle Scholar
  24. 24.
    Biasi V, Cassani T, Costa E, Scroccaro G Precisazioni sulle classificazioni e i parametri utilizzati nelle elaborazioni. In: Societa` Italiana di Farmacia Ospedaliera e dei Servizi Farmaceutici delle Aziende Sanitarie. Report SIFO-IMS sulle prescrizioni ospedaliere 2008-9. 2009; Verona: SIFO; p. 7–8.Google Scholar
  25. 25.
    IMS Institute for Heathcare Informatics. Medicine use and shifting costs of healthcare a review of the use of medicines in the United States in 2013. Report 2014 IMS Health Incorporated.
  26. 26.
    Gruppo di lavoro OsMed. L’uso dei farmaci in Italia. Rapporto nazionale anno 2013. 2014; Roma: Il Pensiero Scientifico.Google Scholar
  27. 27.
    Deshpande A, Pasupuleti V, Thota P, Pant C, Mapara S, Hassan S, et al. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol. 2013;28(2):235–42.CrossRefPubMedGoogle Scholar
  28. 28.
    American Society of Health-System Pharmacists. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. 1999;56:347–79.Google Scholar
  29. 29.
    Madsen KR, Lorentzen K, Clausen N, Oberg E, Kirkegaard PR, Maymann-Holler N, et al. Guideline for stress ulcer prophylaxis in the intensive care unit. Dan Med J. 2014;61(3):C4811.PubMedGoogle Scholar
  30. 30.
    Krag M, Perner A, Wetterslev J, Møller MH. Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. Acta Anaesthesiol Scand. 2013;57(7):835–47.CrossRefPubMedGoogle Scholar
  31. 31.
    Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006;1(1):13–20.CrossRefPubMedGoogle Scholar
  32. 32.
    Herzig SJ, Vaughn BP, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for nosocomial gastrointestinal tract bleeding. Arch Intern Med. 2011;171(11):991–7.PubMedCentralCrossRefPubMedGoogle Scholar
  33. 33.
    Yachimski PS, Farrell EA, Hunt DP, Reid AE. Proton pump inhibitors for prophylaxis of nosocomial upper gastrointestinal tract bleeding: effect of standardized guidelines on prescribing practice. Arch Intern Med. 2010;170(9):779–83. doi: 10.1001/archinternmed.2010.51.PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Chu MP, Ghosh S, Chambers CR, Basappa N, Butts CA, et al. Gastric acid suppression is associated with decreased erlotinib efficacy in non-small-cell lung cancer. Clin Lung Cancer. 2012;16(1):33–9.CrossRefGoogle Scholar
  35. 35.
    Jianu CS, Lange OJ, Viset T, Qvigstad G, Martinsen TC, Fougner R, et al. Gastric neuroendocrine carcinoma after long-term use of proton pump inhibitor. Scand J Gastroenterol. 2012;47:64–7.CrossRefPubMedGoogle Scholar
  36. 36.
    North of England Dyspepsia Guideline Development Group. Dyspepsia: managing dyspepsia in adults in primary care. London: NICE Clinical Guidelines, No. 17. 2004.Google Scholar
  37. 37.
    Larsen MD, Schou M, Kristiansen AS, Hallas J. The influence of hospital drug formulary policies on the prescribing patterns of proton pump inhibitors in primary care. Eur J Clin Pharmacol. 2014;70:859–65.CrossRefPubMedGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  • Maria Meli
    • 1
    Email author
  • Maria Pia Raffa
    • 1
  • Renato Malta
    • 2
  • Ilaria Morreale
    • 1
  • Luigi Aprea
    • 3
  • Natale D’Alessandro
    • 1
  1. 1.Clinical Pharmacology Unit, Department of Hospital General ServicesAzienda Ospedaliera Universitaria Policlinico “P. Giaccone”PalermoItaly
  2. 2.Department of Biopathology and Medical BiotechnologyUniversity of Palermo, Policlinico “P. Giaccone”PalermoItaly
  3. 3.Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”PalermoItaly

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