A Pharmacy-Managed Intravenous to Enteral Proton-Pump Inhibitor Conversion Program

Abstract

This article describes a pharmacy-managed, intravenous (IV) to enteral proton-pump inhibitor (PPI) program at a 377-bed tertiary care, teaching community hospital. IV pantoprazole was not restricted by indication, service, or patient location. Pharmacy converted any eligible patient prescribed an IV PPI to either pantoprazole tablets or lansoprazole capsules, packets, or enteral suspension according to protocol. Over a four-month evaluation period, 113 patients (mean age of 66 years) were prescribed IV PPIs for primarily suspected or documented GI bleeding. Gastroenterology specialists initiated 85% of IV PPI therapy. The most common dosage of IV PPI was 40 mg, once or twice daily with a median duration of 3 to 4 days. Continuous infusion IV PPI therapy was used for only two patients, both with GI bleeding. IV pantoprazole was converted to an enteral PPI in 73 of 113 patients in dosages of pantoprazole 40 mg or lansoprazole 30 or 60 mg administered once (32%) or twice (68%) daily. Pharmacists initiated 34% of the conversions. The total PPI expenditure was $6200 during the evaluation period. Daily acquisition cost savings, based on nominal pricing, ranged from approximately $5 to $25. Initial evaluation of the conversion program resulted in protocol revision and education of the medical staff, in an effort to minimize days of IV PPI use and encourage transition to enteral therapy. The protocol conversion dosage of lansoprazole 60 mg twice daily was changed to 30 mg twice daily and enteral pantoprazole tablets were deleted from the protocol (all IV PPI is converted to lansoprazole, 30 mg twice daily). Although IV pantoprazole remained on the hospital formulary, the medical staff were educated about the relative effectiveness of IV and enteral PPI therapy and the use of histamine-2 receptor antagonists for various indications. Prescribers of IV pantoprazole are now required to document the rationale for use. The Pharmacy and Therapeutics Committee will continue to explore the role IV PPI therapy, based on efficacy, safety, and cost.