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JOHN W. DEVLIN, PHARM.D., BCPS, FCCM, is Associate Professor, Northeastern University School of Pharmacy, and Clinical Pharmacist, Medical Intensive Care Unit, Tufts-New England Medical Center, Mugar #206, 360 Huntington Avenue, Boston, MA 02115 (j.devlin{at}neu.edu).

Purpose. The rationale for limiting the proton pump inhibitor (PPI) products included in an institutional formulary, factors to consider when making formulary decisions about PPI products, the results and limitations of cost-effectiveness analyses of PPI therapy in critically ill patients, the role of clinical practice guidelines in improving PPI use in the intensive care setting, and how these guidelines can be developed are discussed. Summary. Therapeutic interchange may make it possible to limit the number of PPI products included in the formulary and reduce costs without compromising the efficacy or safety of drug therapy. The results of studies comparing the pharmacokinetics, pharmacodynamics, and efficacy of different PPI dosage forms and routes of administration; practical considerations; safety; and costs are among the factors to consider when making formulary decisions. Some of the newer oral PPI products offer advantages over older ones in improved palatability and ease of preparation, storage, and administration. The cost-effectiveness of intravenous (i.v.) PPIs for preventing the recurrence of peptic ulcer bleeding has been demonstrated, but the cost-effectiveness of oral therapy for this indication and both oral and i.v. therapy for preventing stress-related mucosal bleeding has not been well established. Conclusion. Intravenous PPIs are cost-effective for patients at risk for the recurrence of peptic ulcer bleeding. The introduction of new oral PPI products that can be administered as a suspension has expanded the therapeutic options for critically ill patients. The use of clinical practice guidelines can optimize the use of PPIs in the intensive care setting. Index terms: Costs; Critical illness; Decision-making; Dosage forms; Drug administration; Drug administration routes; Economics; Formularies; Gastrointestinal drugs; Gastrointestinal hemorrhage; Hospitals; Pharmacodynamics; Pharmacokinetics; Protocols; Stability; Storage; Substitution; Taste; Toxicity; Ulcers