Appropriateness of proton pump inhibitor prescription for prevention of gastrointestinal bleeding in patients receiving warfarin: a real world, database study.

BACKGROUND: Proton pump inhibitors (PPIs) are recommended for preventing gastrointestinal bleeding (GIB) in patients on warfarin who have risk factors. However, real-world data on the appropriateness of these prescriptions are limited. This study aimed to evaluate the appropriateness of PPI prescriptions for GIB prevention in a cohort of patients receiving warfarin. METHODS: We conducted a retrospective cohort study at a university hospital using data from 2018 to 2023. Adult patients (≥ 18 years) on continuous warfarin therapy were included. We identified four key guideline-recommended indications for PPI prophylaxis: (1) age > 65 years, (2) history of peptic ulcer disease (PUD), (3) concurrent antiplatelet use, and (4) concurrent NSAID/corticosteroid use. Guideline-adherent care was assessed by quantifying two key metrics: under-prescription (absence of a PPI in patients with ≥ 1 indication) and over-prescription (presence of a PPI in patients with no indications). RESULTS: Of 2,366 eligible patients, 1,789 (75.6%) had at least one indication for PPI therapy. Within this high-risk group, 1,178 patients (65.8%) were under-prescribed. Among the 577 patients with no GIB risk indications, 138 (23.9%) were over-prescribed. The rate of PPI use in high-risk patients increased with the number of risk factors (from 26.8% with one factor to 66.7% with four). Patients with a history of PUD had the highest prescription rate (54.4%), while patients aged > 65 years had one of the lowest (36.2%). CONCLUSIONS: In this real-world cohort, PPIs were significantly under-prescribed for GIB prevention in high-risk patients on warfarin, with nearly two-thirds not receiving indicated therapy. Conversely, over-prescription occurred in nearly a quarter of low-risk patients. These findings highlight a critical gap in translating guidelines into practice and suggest a need for targeted educational interventions for prescribers.