Clinical Audit of De-escalation from Intravenous to Oral Proton Pump Inhibitor Therapy
DOI:
https://doi.org/10.65761/pjcr.2026.310Keywords:
Proton pump inhibitors, IV-to-oral conversion, medication stewardship, inpatient prescribing, clinical auditAbstract
Background: Proton pump inhibitors (PPIs) are widely used in hospitalized patients, but intravenous (IV) therapy may be unnecessarily continued after clinical stabilization and restoration of oral intake. Timely IV-to-oral de-escalation is an important component of medication stewardship that may reduce unnecessary parenteral treatment and associated costs. To evaluate the appropriateness, timing, and potential barriers to IV-to-oral PPI de-escalation among hospitalized adults in the Department of Internal Medicine, Lady Reading Hospital, Peshawar, Pakistan.
Methods: A clinical audit framework was applied to a dataset of 210 hospitalized adults receiving IV PPI therapy. Eligibility for conversion was assessed according to clinical stability, tolerance of oral intake, and absence of an ongoing indication for IV therapy. The proportion appropriately converted, time to conversion, appropriateness of the oral regimen, and factors associated with delayed or absent conversion were evaluated.
Results: Of 210 patients, 180 (85.7%) met predefined criteria for IV-to-oral conversion. Among eligible patients, 154 (85.6%) were appropriately converted, representing 73.3% of the overall cohort. The median time to conversion was 48 hours (IQR, 36–72). Pantoprazole was the most frequently prescribed IV PPI (78.1%). Among converted patients, 143 (92.9%) received an appropriate oral dose and frequency, while 11 (7.1%) received potentially excessive dosing. Twenty-six (14.4%) eligible patients experienced delayed or absent conversion. Common reasons for continued or delayed IV therapy included persistent clinical indications, suspected or active upper gastrointestinal bleeding, inability to tolerate oral intake, and hemodynamic instability. No statistically significant associations were observed between conversion and age, sex, comorbidity, or IV dosing frequency.
Conclusion: IV-to-oral PPI de-escalation represents a practical target for inpatient medication stewardship. Standardized conversion criteria and timely medication review may improve prescribing efficiency and reduce unnecessary IV PPI exposure. These findings are based on data and require validation using actual audit records.
References
1. Scarpignato C, Hunt RH. Acid suppressant therapy: a step forward with potassium-competitive acid blockers. Current Treatment Options in Gastroenterology. 2021 Mar;19(1):94-132. https://doi.org/10.1007/s11938-020-00330-x
2. Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian Journal of Gastroenterology. 2023 Oct;42(5):601-28. https://doi.org/10.1007/s12664-023-01428-7
3. Mari A, Marabotto E, Ribolsi M, Zingone F, Barberio B, Savarino V, Savarino EV. Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future. Expert Review of Clinical Pharmacology. 2023 Oct 3;16(10):913-23. https://doi.org/10.1080/17512433.2023.2252327
4. Ierardi E, Losurdo G, La Fortezza RF, Principi M, Barone M, Di Leo A. Optimizing proton pump inhibitors in Helicobacter pylori treatment: Old and new tricks to improve effectiveness. World journal of gastroenterology. 2019 Sep 14;25(34):5097. https://doi.org/10.3748/wjg.v25.i34.5097
5. Prabhoo RY, Pai UA, Wadhwa A, Pillai BV, D'souza C, Wadhawan M, Bhatnagar M, Prabhoo MR, Shetty S, Seshadri VP, Bhatnagar S. Multidisciplinary consensus for rationalizing the use of acid suppressants in children and adults: CONFOR. Euroasian journal of hepato-gastroenterology. 2024 Jan;14(1):99. https://doi.org/10.5005/jp-journals-10018-1430
6. Lenoir C, El Biali M, Luthy C, Grosgurin O, Desmeules JA, Rollason V. Snapshot of proton pump inhibitors prescriptions in a tertiary care hospital in Switzerland: less is more?. International journal of clinical pharmacy. 2019 Dec;41(6):1634-41. https://doi.org/10.1007/s11096-019-00929-w
7. Stanley AJ, Laine L. Management of acute upper gastrointestinal bleeding. Bmj. 2019 Mar 25;364. https://doi.org/10.1136/bmj.l536
8. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Gonçalves TC, Dinis-Ribeiro M. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline–Update 2021. Endoscopy. 2021 Mar;53(03):300-32. DOI: 10.1055/a-1369-5274
9. Reynolds PM, MacLaren R. Re‐evaluating the utility of stress ulcer prophylaxis in the critically ill patient: a clinical scenario‐based meta‐analysis. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2019 Mar;39(3):408-20. https://doi.org/10.1002/phar.2172
10. Mendes JJ, Silva MJ, Miguel LS, Gonçalves MA, Oliveira MJ, Oliveira CD, Gouveia J. Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit. Revista Brasileira de terapia intensiva. 2019;31:5-14. https://doi.org/10.5935/0103-507X.20190002
11. Cook D, Deane A, Lauzier F, Zytaruk N, Guyatt G, Saunders L, Hardie M, Heels-Ansdell D, Alhazzani W, Marshall J, Muscedere J. Stress ulcer prophylaxis during invasive mechanical ventilation. New England Journal of Medicine. 2024 Jul 4;391(1):9-20. DOI: 10.1056/NEJMoa2404245
12. Csiki E, Szabó H, Hanák L, Szakács Z, Kiss S, Vörhendi N, Pécsi D, Hegyi E, Hegyi P, Erőss B. Oral proton pump inhibitors may be as effective as intravenous in peptic ulcer bleeding: a systematic review and meta-analysis. Clinical and Translational Gastroenterology. 2021 Apr 14;12(4):e00341. https://doi.org/10.14309/ctg.0000000000000341
13. Fan X, Chen D, Bao S, Dong X, Fang F, Bai R, Zhang Y, Zhang X, Tang W, Ma Y, Zhai X. Prospective prescription review system correlated with more rational PPI medication use, better clinical outcomes and reduced PPI costs: experience from a retrospective cohort study. BMC Health Services Research. 2023 Sep 20;23(1):1014. https://doi.org/10.1186/s12913-023-09931-5
14. Khoury N, Stepensky D, Abu Freha N, Mahamid M, Khoury T, Mari A. Predictive factors associated with inappropriate intravenous proton pump inhibitors use in hospitalized patients: a case-control study. Medicina. 2024 Dec 25;61(1):10. https://doi.org/10.3390/medicina61010010
15. Akkawi ME, Elnaem MH. Evaluation of the prescribing of proton pump inhibitors as stress ulcer prophylaxis for non-ICU patients in a Malaysian tertiary hospital. Drugs & Therapy Perspectives. 2020 Nov;36(11):529-34. https://doi.org/10.1007/s40267-020-00770-6
16. Bischoff LM, Faraco LS, Machado LV, Bialecki AV, ALMEIDA GM, Becker SC. Inappropriate usage of intravenous proton pump inhibitors and associated factors in a high complexity hospital in Brazil. Arquivos de Gastroenterologia. 2021 Apr 23;58(01):32-8. https://doi.org/10.1590/S0004-2803.202100000-07
17. Clarke K, Adler N, Agrawal D, Bhakta D, Sata SS, Singh S, Gupta A, Pahwa A, Pherson E, Sun A, Volpicelli F. Reducing overuse of proton pump inhibitors for stress ulcer prophylaxis and nonvariceal gastrointestinal bleeding in the hospital: a narrative review and implementation guide. Journal of hospital medicine. 2021 Jul;16(7):417-23. https://doi.org/10.12788/jhm.3637
18. Samar R, Ali SA, Samar V, Mushtaq MZ, Humayun A. SHORT COMMUNICATION-Inappropriate use of proton pump inhibitor for stress ulcer prophylaxis in a tertiary care hospital in Karachi, Pakistan. Pak J Pharm Sci. 2021 Nov;34(6):2253-2255. PMID: 35034888. https://doi.org/10.36721/PJPS.2021.34.6.REG.2253-2255.1
19. Kahrilas P, Anastasiou F, Bredenoord AJ, El Serag HB, Labenz J, Mendive J, Savarino EV, Sifrim D, Udrescu M, Yadlapati R, Hungin AP. Proton pump inhibitors: rational use and use-reduction–the Windsor Workshop. Digestive Diseases. 2024 Mar 21;42(3):211-20. https://doi.org/10.1159/000538399
20. D'Silva KM, Mehta R, Mitchell M, Lee TC, Singhal V, Wilson MG, McDonald EG. Proton pump inhibitor use and risk for recurrent Clostridioides difficile infection: a systematic review and meta-analysis. Clinical Microbiology and Infection. 2021 May 1;27(5):697-703. https://doi.org/10.1016/j.cmi.2021.01.008
21. Wu LH, Wang JL, Liu YH, Su CC, Yang YK, Lin SJ, Cheng CL. Hospitalized patients on proton pump inhibitors for stress ulcer prophylaxis have a higher risk of Clostridioides difficile infection compared with those on histamine-2 receptor antagonists. Journal of Hospital Infection. 2024 Dec 1;154:9-17. https://doi.org/10.1016/j.jhin.2024.09.016
22. Moreels N, Boven A, Gressani O, Andersson FL, Vlieghe E, Callens S, Engstrand L, Simin J, Brusselaers N. The combined effect of systemic antibiotics and proton pump inhibitors on Clostridioides difficile infection and recurrence. Journal of Antimicrobial Chemotherapy. 2024 Mar;79(3):608-16. https://doi.org/10.1093/jac/dkae012
23. Xun X, Yin Q, Fu Y, He X, Dong Z. Proton pump inhibitors and the risk of community-acquired pneumonia: an updated meta-analysis. Annals of Pharmacotherapy. 2022 May;56(5):524-32. https://doi.org/10.1177/10600280211039240
24. Nie T, Heo YA. Prescribe proton pump inhibitors with care and be aware of the signs of nephrotoxicity. Drugs & Therapy Perspectives. 2023 Apr;39(4):131-5. https://doi.org/10.1007/s40267-023-00984-4
25. Hoff M, Skovlund E, Skurtveit S, Meyer HE, Langhammer A, Søgaard AJ, Syversen U, Forsmo S, Abrahamsen B, Schei B. Proton pump inhibitors and fracture risk. The HUNT study, Norway. Osteoporosis International. 2020 Jan;31(1):109-18. https://doi.org/10.1007/s00198-019-05206-0
26. Gommers LM, Hoenderop JG, de Baaij JH. Mechanisms of proton pump inhibitor‐induced hypomagnesemia. Acta Physiologica. 2022 Aug;235(4):e13846. https://doi.org/10.1111/apha.13846
27. Choudhury A, Jena A, Jearth V, Dutta AK, Makharia G, Dutta U, Goenka M, Kochhar R, Sharma V. Vitamin B12 deficiency and use of proton pump inhibitors: a systematic review and meta-analysis. Expert review of gastroenterology & hepatology. 2023 May 4;17(5):479-87. https://doi.org/10.1080/17474124.2023.2204229
28. Bao J, Zhou L, Xu M, Ma J. The impact of pharmacist intervention on the intravenous-to-oral switch therapy of proton pump inhibitors in cardiovascular surgery. Expert Opinion on Drug Safety. 2023 Jul 3;22(7):611-9. https://doi.org/10.1080/14740338.2023.2172162
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Haroon Ur Rashid, Ihtesham Yousuf, Waqas Ahmad, Adnan Afzal, Abdus Salam, Muhammad Shoaib, Sajid Nawaz
This work is licensed under a Creative Commons Attribution 4.0 International License.
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
