Outcomes in Variceal Bleeding Associated With Continuous Octreotide in Patients With Delayed Endoscopy.

Background: Variceal hemorrhage treatment includes endoscopy within 12 hours of admission and octreotide therapy for 2-5 days post-endoscopy. Duration of pre-endoscopy octreotide can be prolonged when intervention is delayed. Objective: This study aimed to evaluate the impact of extended pre-endoscopy octreotide on rebleeding after endoscopy when comparing short vs long durations of post-endoscopy octreotide. Methods: This was a single center, retrospective cohort evaluating adult cirrhotic patients with esophageal variceal hemorrhage admitted between July 1, 2017 and June 30, 2020. Study groups included patients receiving octreotide ≥12 hours prior to endoscopy followed by ≤ 48 (short course) or >48 hours (standard course) after endoscopy. The primary outcome was post-endoscopy rebleeding, defined as hemoglobin decrease of ≥2 g/dL from baseline or the requirement of ≥1 unit of packed red blood cells. Results: Of the 169 patients included, 88 patients received short course octreotide after endoscopy, and 81 patients received standard course octreotide after endoscopy. Twenty-nine (33%) patients in the short course group and 43 (53.1%) in the standard course group experienced the primary endpoint (OR 2.3, 95% CI 1.24 - 4.29; P = .008). Conclusion: Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when intervention is delayed. Further studies are needed to determine the necessary octreotide duration in delayed endoscopy and varying bleeding risk.

Comparing Anti-Factor Xa and Activated Partial Thromboplastin Levels for Monitoring Unfractionated Heparin.

Background: Lab tests such as activated partial thromboplastin time (aPTT) or anti-factor Xa (anti-Xa) levels are typically used to monitor intravenous unfractionated heparin (IV heparin), with recent evidence suggesting that anti-Xa levels may provide a more accurate measure of anticoagulation. Objective: The Lexington Veterans Affairs Health Care System transitioned from using aPTT to anti-Xa levels in January 2017. This study was conducted to evaluate the efficacy and safety of this change. Methods: This was a retrospective cohort study comparing all patients receiving IV heparin per protocol for at least 24 hours from August 1, 2016, to January 31, 2017 (aPTT group), and February 1, 2017, to July 31, 2017 (anti-Xa group). The primary objective was a comparison of IV heparin doses required to achieve goal range between the 2 cohorts. Secondary objectives included a comparison of time to therapeutic goal, percentage of time within goal range, number of rate changes until therapeutic goal, and adverse outcomes, such as number of bleeds. Results: A total of 155 patients were included in this study. Significantly higher IV heparin doses were required to achieve therapeutic goal in the anti-Xa group, despite significantly fewer IV heparin rate changes required. Anti-Xa monitoring was not associated with an increased risk of adverse events. Conclusion and Relevance: Significantly higher IV heparin doses were required to achieve therapeutic anti-Xa levels after transitioning from an aPTT-based protocol in the largely unstudied veteran population. However, the transition from aPTT to anti-Xa monitoring appears safe and efficacious in these patients.

Outcomes From a Pharmacist - led Proton Pump Inhibitor Stewardship Program at a Single Institution.

Background: Proton pump inhibitors (PPIs) are effective medications for acid-related disorders; however, they are also overused and may be associated with several adverse effects. A PPI stewardship program was implemented at one institution to combat the overuse of PPIs. Objective: The purpose of this study is to evaluate the effectiveness of an inpatient PPI stewardship program in reducing PPI use, both during hospitalization and upon discharge. Methods: This was a retrospective cohort study of all patients admitted to an internal medicine service at a single institution from March 14, 2016, to August 14, 2016, with an intervention by the PPI stewardship team. The primary objective was to determine the percentage of patients who tolerated inpatient and outpatient PPI discontinuation, or dose de-escalations upon discharge. Secondary objectives included the identification of risk factors for intolerance of PPI discontinuation, the occurrence of gastrointestinal (GI) complications after PPI discontinuation, and the percentage of patients who required "as needed" acid suppressive therapy (AST) with an antacid or histamine-2 receptor antagonist (H2RA) to control their symptoms while hospitalized. Results: During the study time period, 537 patients with an active outpatient prescription for a PPI were admitted to an internal medicine team with 41.0% (n = 220) not meeting criteria for inpatient continuation. Of these patients, 95.9% (n = 211) tolerated inpatient PPI discontinuation, with 83.4% (n = 176) not requiring any "as needed" AST during hospitalization. Upon discharge, 57.1% patients (n = 24 of 42) tolerated PPI discontinuation at 3 months, while 81.8% patients (n = 18 of 22) tolerated PPI dose de-escalations at 3 months. Risk factors for intolerance of inpatient PPI discontinuation were a higher body mass index (BMI) (33.7 vs 30.3 kg/m2, P = .046) and longer length of stay (7.0 vs 4.0 days, P = .03), while longer duration of PPI use (9.0 vs 5.5 years, P = 0.03) was identified as a risk factor for intolerance of outpatient PPI discontinuation. One patient experienced reflux esophagitis 2 months after PPI discontinuation. Conclusion: A PPI stewardship program at a single institution resulted in the reduction of inappropriate PPI use in both the inpatient and outpatient settings.