Stress Ulcer Prophylaxis

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Stress Ulcer Prophylaxis

Purpose: To provide clinicians with evidence-based recommendations for initiation and discontinuation of pharmacologic stress ulcer prophylaxis (SUP) 

Section 1: Indication of Pharmacologic Stress Ulcer Prophylaxis Therapy

1.           SUP is recommended in the following situations:

a.           Patients when mechanical ventilation for more than 48 hours is likely (Strong Recommendation, High Quality of Evidence)

b.           Coagulopathy defined as platelet count < 50,000/μL, INR > 1.5, or PTT > 2 times the control value while not on exogenous anticoagulation (Strong Recommendation, High Quality of Evidence)

c.            Acute traumatic brain injury with Glasgow Coma Score ≤10 or inability to obey simple commands (Strong Recommendation, Moderate Quality of Evidence)

d.           Major thermal injury (≥20% of total body surface area) (Strong Recommendation, Moderate Quality of Evidence)

2.           SUP may be considered in the following situations:

a.           Acute spinal cord injury (Conditional Recommendation, Low Quality of Evidence)

b.           Partial hepatectomy in the ICU (Conditional Recommendation, Low Quality of Evidence)

c.            Spontaneous subarachnoid hemorrhage, particularly in those with high risk of cerebral vasospasm (or vasospasm present) (Conditional Recommendation, Low Quality of Evidence)

d.           History of GI ulceration or bleeding within 12 months before admission to the ICU (Conditional Recommendation, Very Low Quality of Evidence)


Section 2: Selection of Pharmacologic Stress Ulcer Prophylaxis Agent: 

1.           A histamine H2 antagonist (H2RA) or proton pump inhibitor (PPI) are considered first-line agents for SUP (Strong Recommendation, Moderate Quality of Evidence)

a.           Either a H2RA or PPI may be given first line for SUP and clinicians should use patient specific factors to guide agent selection (Conditional Recommendation, Very Low Quality of Evidence)

2.           Sucralfate is an alternative agent for adults unable to tolerate an H2RA or PPI (Moderate Recommendation, High Quality of Evidence)

3.           An oral or enteral route is preferred for both PPIs and H2RAs when feasible. (Strong Recommendation, Low Quality of Evidence)

 


Section 3: Discontinuation of Pharmacologic Stress Ulcer Prophylaxis Therapy: 

1.           SUP should be discontinued if a patient no longer meets an indication listed in Section 1 and does not have an alternate indication (examples included in Table 3) (Strong Recommendation, Moderate Quality of Evidence)

a.           Clinicians should assess the indication for stress ulcer prophylaxis daily, upon admission and discharge, and upon a change in the level of care (Strong Recommendation, Moderate Quality of Evidence)

b.           Discontinuation of unnecessary therapy is warranted as acid-suppressive agents have been associated with an increased risk of pneumonia, Clostridium difficile, drug-drug interactions, nutritional deficiencies, and increased costs (Strong Recommendation, Moderate to High Quality of Evidence)

2.           SUP may not provide added benefit in patients tolerating enteral nutrition defined as >50% of goal feeds due to improved splanchnic blood flow and possible reduction in gastrointestinal bleeding rates (Conditional Recommendation, Low Quality of Evidence)

a.           Literature is unclear regarding the location of feeds (gastric versus post-pyloric) and the effects of reducing the risk for ulceration  

b.           It may be reasonable to continue SUP therapy despite enteral feeding in patients exhibiting hypersecretory states (i.e. burns, traumatic brain injury)

c.            Clinicians are encouraged to individually weigh the risk-benefit assessment when deciding whether to continue or withhold SUP for patients tolerating enteral feeds

3.           Considerations should be made for additional indications for H2RA or PPI therapy based on based medical history or current conditions



 

References

 

1.            Cook D, Fuller H, Guyatt G, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994;330(6):377-381.

2.            ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis DEVELOPED THROUGH THE ASHP COMMISSION ON THERAPEUTICS AND APPROVED BY THE ASHP BOARD OF DIRECTORS ON. Am J Health Syst Pharm. 1999;56(4):347-379.

3.            Guillamondegui OD, Gunter OL, Bonadies JA, et al. PRACTICE MANAGEMENT GUIDELINES FOR STRESS ULCER PROPHYLAXIS. www.east.org.

4.            Granholm A, Krag M, Marker S, Alhazzani W, Perner A, Møller MH. Predictors of gastrointestinal bleeding in adult ICU patients in the SUP-ICU trial. Acta Anaesthesiologica Scandinavica. 2021;65(6):792-800. doi:10.1111/aas.13805

5.            Ali D, Barra ME, Blunck J, et al. Stress-Related Gastrointestinal Bleeding in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Observational Study. Neurocritical Care. 2021;35:39-45. doi:10.1007/s12028-020-01137-5

6.            Ye Z, Reintam Blaser A, Lytvyn L, et al. Gastrointestinal bleeding prophylaxis for critically ill patients: A clinical practice guideline. The BMJ. 2020;368:l6722. doi:10.1136/bmj.l6722

7.            Alhazzani W, Alenezi F, Jaeschke RZ, Moayyedi P, Cook DJ. Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: A systematic review and meta-analysis. Critical Care Medicine. 2013;41(3):693-705. doi:10.1097/CCM.0b013e3182758734

8.            Deliwala SS, Hamid K, Goyal H, et al. Proton Pump Inhibitors Versus Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Meta-analysis and Trial Sequential Analysis. J Clin Gastroenterol. Published online 2021. doi:10.1097/MCG.0000000000001562

9.            Barbateskovic M, Marker S, Granholm A, et al. Stress ulcer prophylaxis with proton pump inhibitors or histamin-2 receptor antagonists in adult intensive care patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med. 2019;45:143-158. doi:10.1007/s00134-019-05526-z

10.         Krag M, Marker S, Perner A. Pantoprazole in Patients at Risk for Gastrointestinal  Bleeding in the ICU. N Engl J Med. 2018;379(23):2199-2208. doi:10.1056/NEJMoa1714919

11.         Blackett JW, Faye AS, Phipps M, Li J, Lebwohl B, Freedberg DE. Prevalence and Risk Factors for Inappropriate Continuation of Proton Pump Inhibitors After Discharge From the Intensive Care Unit. Mayo Clinic Proceedings. 2021;96(10):2550-2560. doi:10.1016/j.mayocp.2020.07.038

12.         Anh Nguyen P, Islam M, Galvin CJ, et al. Meta-analysis of proton pump inhibitors induced risk of community-acquired pneumonia. International Journal for Quality in Health Care. 2020;32(5):292-299. doi:10.1093/intqhc/mzaa041

13.         Trifan A, Stanciu C, Girleanu I, et al. Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis. World J Gastroenterol. 2017;23(35):6500-6515. doi:10.3748/wjg.v23.i35.6500

14.         Ogawa R, Echizen H. Drug-Drug Interaction Profiles of Proton Pump Inhibitors. Clin Pharmacokinet. 2010;49(8):509-533.

15.         Heidelbaugh J. Proton pump inhibitors and risk of  vitamin and mineral deficiency:  evidence and clinical implications. Ther Adv Drug Saf. 2013;4(3):125-133. doi:10.1177/2042098613482484

16.         Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006;101(10):2200-2205. doi:10.1111/j.1572-0241.2006.00839.x

17.         Palm NM, McKinzie B, Ferguson PL, et al. Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition. J Intensive Care Med. 2018;33(7):424-429. doi:10.1177/0885066616678385

18.         Selvanderan SP, Summers MJ, Finnis ME, et al. Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study. Critical Care Medicine. 2016;44(10):1842-1850.

19.         El-Kersh K, Jalil B, McClave SA, et al. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study. Journal of Critical Care. 2018;43:108-113. doi:10.1016/j.jcrc.2017.08.036

20.         Hurt RT, Frazier TH, McClave SA, et al. Stress prophylaxis in intensive care unit patients and the role of enteral nutrition. JPEN J Parenter Enteral Nutr. 2012;36(6):721-731. doi:10.1177/0148607112436978