Compliance in the prescribing of new oral proton pump inhibitors (ppi’s) against local and trust guidelines for inpatients

LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST
Compliance in prescribing for the initiation of new oral Proton Pump Inhibitors
against local and trust guidelines for inpatients.
By Sameer Patel
Project Supervisor: Jean Holmes (Senior Pharmacist)

Background Information

Proton pump inhibitors ( PPI’s) act on inhibiting gastric secretions in parietal cells of the stomach. There are various clinical indications such as prevention of NSAID associated
ulcers, short term treatment of duodenal and gastric ulcers, alongside methotrexate therapy,
and decreasing gastric acid secretion in Zollinger-Ellison syndrome. Patients that are nil by
mouth may be initiated on IV Esomeprazole but cost and trust guidelines should be
considered when switching the patient onto oral PPIs. Cost of PPIs varies greatly from oral
Lansoprazole 30mg costing £3.06 per 28 capsules to oral Esomeprazole (Nexium) 20mg
costing £18.50 per 28 tablets1.
Under Lancashire Teaching Hospital’s guidelines the initiation of PPI states that
Lansoprazole as first line orally. It is the most cost effective choice and is clinically
appropriate.

Aim

To measure the compliance of oral PPI initiation with reference to trust guidelines.

Objectives
1. Determine the percentage of patients that are switched from IV Esomeprazole to oral Esomeprazole instead of oral Lansoprazole. 2. Determine the number of patients initiated on 1st line PPIs compared to 2nd line PPIs. 3. Determine how many patients are discharged on 2nd line PPIs without a pharmacy intervention or the intervention excluded without reason. 4. Determine the number of patients with a pharmaceutical intervention switched to Lansoprazole from Esomeprazole due to incorrect prescribing and/or not previously admitted on a PPI. A questionnaire was given to pharmacists at both hospital sites (Preston and Chorley) to monitor the initiation of new oral PPI’s on the wards for a period of 2 weeks. The questionnaire included an additional comment section to record reasons not included in the list provided on the choice of PPI. Results
There were 48 patients across both sites which were recorded to have new oral PPI’s
prescribed.
Pie Chart to show initiation of PPI's

Rabeprazole was prescribed alongside Methotrexate, an intervention was suggested but it was
not actioned. Both Esomeprazole initiations were due to IV to oral change that was incorrect,
but was changed to Lansoprazole by the pharmacist.
Discussion/ Conclusion
Results show that the majority of prescribing PPIs follows the trust’s guidelines and that 1st line PPI (Lansoprazole) was prescribed 93% of the time. 4% of the PPI initiations were for oral Esomeprazole following IV therapy without a clinical reason documented for its choice. Pharmacist’s intervention managed to change 100% of these cases to Lansoprazole. Rabeprazole was started on one occasion, there was an attempt for it to be changed to a 1st line PPI but there was no success. This non-compliance to trust guidelines would cost the NHS an additional £15 a month. In conclusion, although the guidelines were followed pharmacist’s played an important role in suggesting the change to Lansoprazole provided savings to the trust. Limitations to this study were that there may have been patients not seen by a pharmacist and hence initiation of a PPI may not have been documented. The time of data
collection was half way through the year, therefore junior doctors may have been made aware
of the guidelines through previous interventions and hence the number of interventions may
not have been as high as if the study was done in August.
References:

1. British National Formulary 58 September 2009

Source: http://www.pharmacyworkforcenw.nhs.uk/uploads/018494b41991f4688c8f453a9c981d43/Lancashire%20Teaching%20Hospitals%20%20-%20Sameer%20Patel.pdf?download=true