Proton pump inhibitor formulary considerations in the acutely Ill: Part 1 - Pharmacology, pharmacodynamics, and available formulations

OBJECTIVE: To review important proton pump inhibitor (PPI) pharmacologic, pharmacokinetic, and pharmacodynamic principles in acutely ill patients, compare PPI formulation options for patients unable to swallow a tablet or capsule, and provide clinicians with guidance when making hospital formulary decisions with this class of agents. DATA SOURCES: MEDLINE (1966-May 2005) and the Cochrane Library databases were searched using the key words proton pump inhibitor, acid suppression, peptic ulcer disease, gastrointestinal bleeding, stress ulcer prophylaxis, and critical illness. Bibliographies of cited references were reviewed, and a manual search of abstracts from recent gastroenterology, critical care, and surgery scientific meetings was completed. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated, and all information deemed relevant was included for this review. DATA SYNTHESIS: PPIs have become a mainstay for acute acid suppression in hospitalized patients over other therapeutic options. Various commercially available PPI products are available for administration, either enterally or parenterally, to patients unable to swallow a tablet or capsule. Newer oral PPI formulations offer numerous advantages over older products. The results of studies comparing the pharmacokinetics and pharmacodynamics of different PPI dosage forms and routes of administration are among the factors to consider when making formulary decisions. CONCLUSIONS: While the introduction of new PPI products has expanded the therapeutic options for acid suppression in acutely ill patients, a number of unresolved questions remain surrounding the interchangeability of these products, the clinical significance of one PPI formulation over the other, and how oral/enteral PPI therapy should be used as step-down therapy after parenteral PPI therapy.