RxFiles: Staying Up to Date
by Andrea Sikora Newsome, PharmD
“Well, UpToDate says that PPIs are superior for stress ulcer prophylaxis.”
As a pharmacist, most sentences starting with “UpToDate says” do not bode well. UpToDate is one of several electronic tertiary resources that attempts to summarize a myriad of medical topics ranging from seasonal allergies to management of neuromuscular blockade in acute respiratory distress syndrome. Overall, these resources provide a wealth of information. The figures and flowcharts are top notch. Plus, it provides primary literature citations that links directly to Medline. The issue is user error, wherein a resident reads the one-liner on a topic and does not dig any deeper.
This particular resident was replying to my recommendation that we utilize famotidine over pantoprazole for stress ulcer prophylaxis (SUP). Although this is an area of some clinical controversy, many clinicians interpret the available literature as saying that famotidine and other histamine two (H2) receptor blockers provide similar stress ulcer protection to pantoprazole and other proton pump inhibitors (PPIs), and that H2 blockers may have a reduced incidence of infections like ventilator-associated pneumonia, Clostridium difficile infections, and other infections. The cost difference has historically been very significant as well (although as PPIs become generic, this difference has diminished). Thus, in the absence of a compelling indication for a PPI, H2 receptor blockers are generally considered the preferred agent for SUP.
About every eight weeks, a resident explains what UpToDate says to me about PPIs, so my answer is already prepared. “I know the line you’re talking about, but have you read the 2013 Critical Care Medicine meta-analysis it actually cites supporting that statement?”
So far, none of them have, which is really unfortunate. First and foremost, the information they have is incomplete, compromising the quality of patient care delivery. Secondly – perhaps more disheartening – it implies that residents do not appreciate how much of medicine is practiced where there are no absolute answers. Realizing how rarely one can assuredly cite a medical fact like “Smoking is globally detrimental for your health” is an important concept to appreciate. The line the residents were citing (“For critically ill patients who are able to receive enteral medications and in whom stress ulcer prophylaxis is indicated, an oral proton pump inhibitor (PPI) is preferred rather than an alternative prophylactic agent.”) sounds definitive but warrants further investigation.
If the resident had even just pulled up the abstract, they would have noted caveats. The abstract cautions, “The robustness of this conclusion is limited by the trial methodology, differences between lower and higher quality trials, sparse data, and possible publication bias.” If one went a step further to read the actual discussion of the article, the authors dedicate an entire paragraph to recommending “cautious interpretation of these results” due to trial quality (lack of blinding, poorly defined endpoints, etc.) and evidence of publication bias.
This practice of just reading the one-liner appears disturbingly pervasive, especially when I see this cited in medical notes in the patient’s chart. Truly staying up to date requires a love of learning and playing devil’s advocate to what you read.
Andrea Sikora Newsome, PharmD, is a Critical Care Pharmacy Specialist at Georgia Regents University, North Augusta, South Carolina.