Changes in Usage and Costs of Acid

The key finding in our analysis was the substantial increase in PPI usage after the hospital formulary was changed to low-cost products. This increased usage was apparent for enteral and IV formulations and evident only in the ICU. Concurrently, the use of H2RA enteral and IV products decreased significantly in the ICU. Despite this change in the use of acid-suppressant therapies in the ICU, the cost of medications per patient-day was reduced.

The use of PPIs in the ICU increased despite the presence of a guideline directing the use of IV PPI therapy and an algorithm for SRMD that promoted H2RA therapy. We did not perform an assessment of adherence to these protocols after the formulary switch, so their effectiveness might have declined with the introduction of less costly PPI therapies. This is partly evident by the diminished use of H2RA products in the ICU, which suggests that PPI formulations were substituted for H2RA therapies. kamagra uk

Although we did not assess specific indications, we do not believe that PPI use in the ICU increased as a result of patient characteristics or disease states that necessitated PPI therapy per the P&T committee guidelines. PPI therapy for GI bleeding was considered appropriate before and after formulary change. Therefore, the amplified use was most likely a result of therapy for SRMD.

We believe that the primary driver of the increased use of PPIs in the ICU was the reduced cost of these products after the formulary switch, which probably resulted in less concern for whether other acid-suppressant therapies were warranted and lack of guideline adherence. The addition of low-cost formulary alternatives has been shown to enhance utilization, especially if cost is dependent on incentives for usage. Other potential influences of PPI use in our study included:

  • enhanced promotion of the local product by the drug company after the switch to one PPI brand.
  • the increased use of PPIs in the community setting, resulting in the continuation of therapy upon admission to the ICU.
  • enhanced acceptability of the appropriateness of PPI therapy.
  • the possible influence of literature supporting the use of PPIs for SRMD therapy that was published after the initial assessment period.

The use of PPIs outside the ICU did not increase in relation to H2RA therapy. This is not surprising, because the costs of oral PPI formulations were essentially unchanged after the formulary switch. Whether this finding represents effective management of appropriate prescribing after the change, or whether it indicates uncontrolled use prior to the formulary change, is unknown.
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It is interesting that the increased use of PPIs in the ICU did not confer their additional use outside the ICU, as would be expected when patients are transferred. This finding supports the notion that enhanced ICU use was probably attributable to SRMD therapy, because PPI regimens would be discontinued as risk factors for bleeding subsided, whereas patients requir­ing PPI therapy for GI bleeding would require long-term oral PPI therapy.

Appropriate discontinuation of PPI therapies at our institution has been reassuring, because some institutions report that 50% of their patients are discharged home with unnecessary acid-suppressant therapies. Because we work in an academic institution, this is a concern; prescribing practices at teaching hospitals influence prescribing practices at local community institutions and among general practitioners.

Several evaluations have been conducted to assess the financial impact of restricting PPI use. The results show that practices such as establishing guidelines directing appropriate use, therapeutic interchange, step-down therapy, and prior authorization limit the use of PPIs and reduce associated costs. Our analysis indicated that although PPI use increased in the ICU, the cost of acid-suppressant therapy per patient-day was reduced. Therefore, restricting the use of PPIs based upon cost is not warranted.

The findings of two retrospective analyses showed that cost savings associated with the formulary switch to less expensive PPIs were negated by increased failure rates. Therefore, PPI therapy should be determined by clinical indications and patient characteristics rather than by cost.


Our assessment is not without limitations. Because we did not determine patient-specific variables, the comparison before and after the switch might have been influenced by differences in patient characteristics or practice changes. Moreover, we were unable to assess the clinical appropriateness of prescribing practices.

Our assessments were based on database analyses at a single institution. Whereas the databases were not modified over the assessment period, it is possible that data entry and extraction might have varied. Similar results at other institutions would validate our data; at present, however, our results might not be representative of, or might not be directly applicable to, those of other institutions.

We assumed that patients received all doses of a specific regimen at the hospital location where the therapy was discontinued, and we applied product costs at the beginning of each time period rather than real-time costs—which might have changed slightly.  kamagra soft tabs


Changing the formulary PPIs to low-cost products was associated with a substantially increased use of PPIs, a decreased use of H2RAs, and reduced costs of acid-suppressant therapies in the ICU. No changes in use or in associated costs were observed outside the ICU.