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Limiting Pantoprazole Infusions

Explore the effectiveness of intermittent bolus vs continuous infusion therapy for upper gastrointestinal bleeding. Discover potential cost savings and recommendations for minimizing infusion use. Follow expert advice for enhanced patient care.

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Limiting Pantoprazole Infusions

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  1. Limiting Pantoprazole Infusions Zlatan Coralic, PharmD, BCPSPharmacy and Therapeutics Committee UCSF Medical Center

  2. Background • Current medical management of upper gastrointestinal bleeding involves the use of a pantoprazole bolus followed by an infusion for 72 hours. • Recent data shows that intermittent pantoprazole boluses are as effective as continuous infusion therapy. • Currently there is a shortage of intravenous pantoprazole. • 72-hour pantoprazole infusion utilizes 14 vials. • Intermittent bolusing uses 6 vials in the same time period.

  3. Intermittent Bolus vs Infusion • 1 meta-analysis (13 trials) of high risk UGIB • Intermittent dosing, effect on rebleeding compared to infusion: • No difference at 3 days • Less at 7 days (RR 0.72) • No difference 30 days • No difference in mortality, surgery, or urgent intervention • Not a superior intervention, but non-inferior with trend favoring intermittent bolusing (rebleeding benefit) JAMA Intern Med 2014;174:1755-62.

  4. What About the Gastric pH? • Two studies of continuous infusion vs bolus: • In 10 critically ill patients no difference for duration of pH >6 twelve hours after treatment (p=0.51) • In 153 UGIB patients no difference for duration of pH >6 during treatment (p=0.18) Crit Care Med. 2001 Oct;29(10):1931-5. ANZ J Surg. 2007 Aug;77(8):677-81.

  5. Report • Panoprazole 1 vial = $3.15 • 1 IVPB NS = $1.26 • Preparation cost = $20 • Number of gtts in 2016 @ UCSF = 3,886 • Total Medical Center cost = $107,098 • Projected cost with change in practice = $42,839 • Potential institutional savings per year = $64,259 • (Patient charge savings=~ $300,000)

  6. Report • The savings likely represent a gross underestimate as the following are not taken into account: • Technician preparation and delivery times • IV Supplies • Nursing time • IV access issues (poor compatibility with other infusions, e.g., octreotide) • Infusions prepared but not given

  7. Recommendations • To minimize use of pantoprazole infusions: • At provider order entry, Apex selection should be restricted to bolus options only • Providers should be able to opt out and order infusions by contacting pharmacy and placing a Non-Formulary request • For all pantoprazole IV orders, the following should be embedded in the yellow order instructions: “UCSF P&T recommends that all adult patients treated for upper gastrointestinal bleeding should receive an initial pantoprazole 80 mg IV bolus, followed by 40 mg IV BID. Pantoprazole continuous infusions are not recommended.” • The infusion requests should be reviewed periodically for appropriateness

  8. Approvals • Dr. Jonathan Terdiman • Director, Adult Gastroenterology Service • Dr. Bradley Sharpe • Associate Division Chief Hospital Medicine • Associate Chief of the Medical Service • Dr. Hameed Bilal & Dr. Francis Yao • Liver Transplant • Medication Safety Committee • Pharmacy & Therapeutics Committee

  9. Special Thanks • William Alegria, PharmD • Dorothy Wang, PharmD • Ashley Thompson, PharmD

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