Why are PPIs underused for the prevention of gastrointestinal bleeding?

A team examines barriers to the use of a proven strategy to protect the stomachs of patients at high risk for bleeding.

9:47 AM

Author | Jina Sawani

pink organs bleeding from stomach in white drawing of body and teal and pink pills floating in air
Justine Ross, Michigan Medicine

Gastrointestinal bleeding is a potentially life-threatening condition. It is often linked to the use of medications like non-steroidal anti-inflammatory drugs, or NSAIDS, like ibuprofen and naproxen, aspirin and blood thinners.

"Many of these drugs are prescribed to individuals who have heart disease," said Jacob E. Kurlander, M.D., M.S., an assistant professor and gastroenterologist at Michigan Medicine and the VA Center for Clinical Management Research. "And while medicines like aspirin and blood thinners like warfarin can be life-saving for patients at risk for heart attacks and strokes, they can also lead to gastrointestinal bleeding."

Proton pump inhibitors, or PPIs, are generally prescribed by physicians to help treat digestive issues like gastroesophageal reflux disease. However, Kurlander notes that their role in the prevention of gastrointestinal bleeding is often overlooked.

"PPIs have gotten a lot of press lately because they've been linked to things like kidney disease, diarrhea and certain mineral deficiencies. But it is far from clear that they actually cause these conditions," said Kurlander. "Of course, this raises the question of whether physicians may be limiting their use of PPIs as a preventative measure for gastrointestinal bleeding."

This notion led Kurlander and a team of experts to examine the "prescribing practices and barriers" associated with the use of PPIs as "gastroprotection" from bleeding. Their research was recently published in the Annals of Family Medicine.

"We wanted to take a look at a diverse group of physicians, so our sample included primary care doctors, cardiologists, gastroenterologists and vascular surgeons," said Kurlander. "All of these specialists routinely treat patients who may benefit from PPIs for bleeding prevention."

The team interviewed the physicians about how they prescribe PPIs, as well as the factors they feel serve as barriers when it comes to using them for bleeding prevention. And they found a few major themes. 

"Many physicians overlooked the effectiveness of PPIs for bleeding prevention and weren't aware of guidelines that recommend them for this purpose," said Kurlander. "As a result, thinking about PPI gastroprotection rarely got prioritized in busy clinic visits, when patients may have many other pressing issues."

Many physicians overlooked the effectiveness of PPIs for bleeding prevention and weren't aware of guidelines that recommend them for this purpose.
Jacob E. Kurlander, M.D., M.S.

In addition, concerns about the adverse effects from PPI use created a reluctance for some physicians to prescribe these drugs: "For PCPs especially, the possibility of side effects are top of mind when they think about PPIs," said Kurlander.

MORE FROM THE LAB: Subscribe to our weekly newsletter

Kurlander notes that for patients who may see many different medical specialists, it can often be unclear who should be responsible for considering whether a PPI is needed for bleeding prevention. And he adds that "it was interesting to see that no single specialty assumed ownership of prescribing PPIs to their patients for the sole purpose of gastroprotection."

When it came to gastroenterologists, vascular surgeons and cardiologists, the consensus was that gastroprotection was something they felt PCPs should actively manage. However, many of the PCPs felt differently.

"We found that PCPs generally felt that if another specialist prescribed a drug that can cause ulcers and bleeding, then they should also prescribe a PPI for gastroprotection," said Kurlander. "Overall, this research helped us understand that there needs to be better coordinated care for these patients. There are a lot of studies published in gastroenterology journals about PPIs and gastroprotection because these specialists are the ones who end up treating patients who develop bleeding ulcers. But to prevent bleeding ulcers in the first place, we need to increase the awareness among PCPs and cardiologists, who prescribe medicines like ibuprofen and aspirin, which are the inciting drugs."

As Kurlander looks to the future, he hopes that this research will lead to some crucial changes.

"If relevant guidelines target both PCPs and specialists at the same time, there will be more clarity about who should prescribe PPIs for gastroprotection, which is often overlooked," he said. "I know it's easier said than done, given that a lot of specialists aren't used to prescribing PPIs for this reason. But it will certainly take a collaborative effort moving forward."

Paper cited: "Barriers to Guideline-Based Use of Proton Pump Inhibitors to Prevent Upper Gastrointestinal Bleeding," Annals of Family Medicine. DOI: 10.1370/afm.2734

Like Podcasts? Add the Michigan Medicine News Break on iTunes, Google Podcasts or anywhere you listen to podcasts.


More Articles About: Industry DX Ulcer Health Care Delivery, Policy, and Economics Medication Interactions Digestive (GI) Conditions
Health Lab word mark overlaying blue cells
Health Lab

This article is from the Health Lab digital publication.

Media Contact Public Relations

Department of Communication at Michigan Medicine

MichMedmedia@med.umich.edu

734-764-2220

Newsletter

Get a weekly digest of medical research and innovation, straight to your inbox.

Subscribe
Featured News & Stories Woman bent over holding chest in light blue sweater.
Health Lab
Physician Perceptions On PPIs
A new study reveals that providers may be recommending patients stop the use of PPI’s in some cases where the benefits would likely outweigh potential side effects.
Health Lab
Many Americans Are Worried About Taking PPIs and Have Tried Stopping Them Without Doctor Approval
A new national study examines patients’ perceptions of proton pump inhibitors, and how they are changing their use of these medications as a result.
eye drawing lab note
Health Lab
Many older adults lack clear eyesight, even with glasses
Vision impairment disproportionately impacts older adults
VAD heart device cooler red and teal
Health Lab
Medicare policy change could increase inequity in heart transplant access, study finds
Patients seen at transplant centers had almost 80% higher odds to receive “bridge-to-transplant” designation
Three hands with two medical bands having the words penicillin allergy disappearing.
Health Lab
Are you still allergic to penicillin?
A new program is finding many diagnosed in childhood with antibiotic allergies are no longer allergic after retesting
pregnant stomach with yellow dots and blue undertone lab note
Health Lab
Few pregnant people who died of overdose, suicide in Michigan received proper treatment before death
A review of maternal deaths suggests most individuals had documented behavioral health conditions but only one-third received appropriate pharmacologic treatment before death