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INTRODUCTION

Proton pump inhibitors (PPIs) are the preferred agents for the management of gastrointestinal (GI) disorders, including Zollinger-Ellison syndrome, nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, Helicobacter pylori infection, and complicated or refractory gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD). Intravenous (IV) therapies are infrequently required for these disorders.

The first-line therapy for uncomplicated GERD and peptic ulcer disease involves H2-receptor antagonists (H2RAs), but many clinicians prefer PPIs because of their higher efficacy in reversing symptoms and in promoting tissue healing. IV H2RAs are the standard of therapy for preventing bleeding from stress-related mucosal disease (SRMD), but some critically ill patients may need to avoid receiving H2RAs, such as patients with associated thrombocytopenia or mental confusion that may be worsened with H2RA administration. cialis professional

Although limited data are available to support the use of IV PPIs for SRMD, enteral PPIs are noted to be equivalent in efficacy to IV H2RAs for this indication. Unfortunately, many critically ill patients are unable to receive enteral medications and require IV PPIs. For managing nonvariceal upper GI bleeding, high-dose IV PPIs have been shown to reduce the rates of re-bleeding and red blood cell transfusion and the need for surgery; these findings have led many clinicians to recommend PPIs before and after endoscopic therapy.

When PPIs were first introduced into the market, the acquisition costs were substantially higher than the costs of H2RAs, many of which were available as generic formulations. In addition, insufficient data supporting the superiority of PPIs over H2RAs for many indications prevented them from becoming first-line agents. Similarly, when IV PPIs first became available, their acquisition costs inhibited their routine use and required implementing restrictive guidelines at many institutions.

In the case of enteral PPI formulations, the emergence of additional data and inexpensive generic products secured their presence as first-line therapy options for many indications. Extrapolation of data from enteral PPI formulations to IV formulations and the emergence of additional IV PPIs enhanced their market presence. The acquisition costs of IV PPIs have steadily declined as their presence in the market has increased.
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At our institution, the implementation of guidelines effectively restricted the use of IV PPIs before the hospital formulary switch to less expensive PPIs. Clinical experience suggests that PPI use, especially IV administration, increased after the formulary change.

The objectives of our analysis were to compare usage patterns of PPIs and H2RAs in the hospital and in the ICU before and after the formulary change and to determine the associated costs.