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Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified
Tanvi Patil1, Kimberly Murphy1, Laura Woodard1
1Veterans Health Administration - Pharmacy, Salem, Virginia, USA.
Insights
Proton pump inhibitor (PPI) co-therapy is underutilized for gastrointestinal bleed (GIB) prophylaxis in veteran patients on combined antithrombotic therapy (CAT). A simplified five-factor risk score (FFRS) shows promise for predicting GIB risk.
Area of Science:
- Internal Medicine
- Gastroenterology
- Pharmacology
Background:
- Combined antithrombotic therapy (CAT) increases gastrointestinal bleed (GIB) risk.
- Proton pump inhibitors (PPIs) are suggested to mitigate GIB in patients on CAT.
Purpose of the Study:
- To assess PPI utilization in veteran patients on CAT.
- To identify clinical predictors of GIB in this population.
- To evaluate risk scores for GIB prediction.
Main Methods:
- Retrospective study of veteran patients on CAT initiated between January 1, 2018 and October 30, 2018.
- Extracted data from computerized patient records.
- Analyzed PPI co-therapy rates, GIB events, mortality, and validated FFRS and HAS-BLED scores.
Main Results:
- Overall PPI co-therapy rate was 40.9%, with only 22.3% for prophylaxis.
- Predictors of GIB included alcohol use, smoking, chronic kidney disease, peptic ulcer disease, and NSAID use.
- Simplified FFRS demonstrated better GIB predictive performance than HAS-BLED score (C-statistic 0.738 vs 0.596).
Conclusions:
- PPI co-therapy is underutilized for GIB prophylaxis in veteran patients on CAT.
- A simplified FFRS shows potential for improved GIB risk prediction in patients on CAT.
Background:
Concomitant use of anticoagulant and antiplatelet agents can increase the risk of gastrointestinal bleed (GIB). Use of proton pump inhibitors (PPIs) has been proposed to decrease the risk of GIB in patients on combined antithrombotic therapy (CAT).
Objective:
To describe the current utilization of PPIs in veteran patients on CAT and associated clinical predictors of GIB.
Methods:
This retrospective study included patients on CAT receiving PPIs, with at least one of the CAT agents initiated between January 1, 2018 and October 30, 2018. Data were extracted from the computerized patient record system. Primary end point included estimating proportion of patients on CAT receiving PPI co-therapy, describing patient characteristics, and identifying clinical predictors of GIB. Secondary outcomes included reporting GIB events and all-cause mortality. Additional outcome was to validate the five-factor risk score (FFRS) for GIB in patients on CAT and compare its overall predictive performance to HAS-BLED score.
Results:
This study reports an overall rate of PPI co-therapy in patients on CAT of 40.9% (484/1181), with only 22.3% of patients on CAT receiving PPI for GIB prophylaxis. There was no difference in the mean follow up duration of PPI users and PPI co-therapy (264.01 vs 271.92 days; p=0.3761). Current alcohol use (p=0.005), current smokers (p=0.022), chronic kidney disease (p=0.004), peptic ulcer disease (p<0.001), and non-steroidal anti-inflammatory drug use (p=0.048) were significant predictors of GIB in multivariate analyses of our study cohort. We further provide exploratory validation that use of a simplified FFRS to predict GIB showed a trend towards better overall predictive performance as compared to HAS-BLED score (C-statistic: 0.738; 95% CI 0.684-0.787 for FFRS vs C-statistic: 0.596; 95% CI 0.538-0.653 for HAS-BLED; p=0.0094).
Conclusion:
This study reports lower rate of PPI co-therapy in veteran patients on CAT per currently available guidance. Further we explore utilization of simplified FFRS model to predict GIB in patients on CAT with long-term PPI co-therapy.
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