Minimize unsuitable use of PPIs for stress ulcers

Avoid "universal" prophylaxis in ICUs and remove order defaults. Lean away from using a prophylactic medication in patients with just one risk factor.
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

As a critical care pharmacist, you will be asked to re-evaluate the use of proton pump inhibitors (PPIs) or H2-blockers for stress ulcer prophylaxis. We know that stress ulcer prophylaxis isn't indicated for floor patients. But many ICU patients don't need it either...

Mounting evidence suggests it doesn't decrease mortality or clinically significant bleeding. The thought is that ICU care has improved in recent years, reducing the overall GI bleeding risk. Plus some evidence suggests enteral nutrition is sufficient to protect against clinically significant GI bleeding.

     Avoid "universal" prophylaxis in ICUs and remove order defaults. Lean away from using a prophylactic medication in patients with just one major risk factor, such as mechanical ventilation or INR above 1.5 or other coagulopathies, if they're tolerating enteral nutrition. But continue to use a prophylactic medication in the sickest patients with multiple risks. It's too soon to say if enteral nutrition alone is enough for them. For example, consider a prophylactic PPI or H2-blocker for a patient who's mechanically ventilated with septic shock and acute kidney injury.

Choose a PPI or an H2-blocker, neither has a clear advantage. There's no proof H2-blockers increase the risk of altered mental status when used for stress ulcer prophylaxis. And concerns about increased pneumonia or C. difficile aren't panning out for SHORT-term PPI use. Monitor the need for prophylactic medications daily and stop when risks resolve. Don't let prophylaxis continue on transfer to the floor or at discharge. Also require an indication to target unnecessary use.

REFERENCES

  • Cook D, Guyatt G. Prophylaxis against Upper Gastrointestinal Bleeding in Hospitalized Patients. N Engl J Med. 2018 Jun 28;378(26):2506-2516. Available at: https://www.nejm.org/doi/10.1056/NEJMra1605507

    Krag M, Marker S, Perner A, Wetterslev J, Wise MP, Schefold JC, Keus F, Guttormsen AB, Bendel S, Borthwick M, Lange T, Rasmussen BS, Siegemund M, Bundgaard H, Elkmann T, Jensen JV, Nielsen RD, Liboriussen L, Bestle MH, Elkjær JM, Palmqvist DF, Bäcklund M, Laake JH, Bådstøløkken PM, Grönlund J, Breum O, Walli A, Winding R, Iversen S, Jarnvig IL, White JO, Brand B, Madsen MB, Quist L, Thornberg KJ, Møller A, Wiis J, Granholm A, Anthon CT, Meyhoff TS, Hjortrup PB, Aagaard SR, Andreasen JB, Sørensen CA, Haure P, Hauge J, Hollinger A, Scheuzger J, Tuchscherer D, Vuilliomenet T, Takala J, Jakob SM, Vang ML, Pælestik KB, Andersen KLD, van der Horst ICC, Dieperink W, Fjølner J, Kjer CKW, Sølling C, Sølling CG, Karttunen J, Morgan MPG, Sjøbø B, Engstrøm J, Agerholm-Larsen B, Møller MH; SUP-ICU trial group. Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU. N Engl J Med. 2018 Dec 6;379(23):2199-2208. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1714919?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

    Reynolds PM, MacLaren R. Re-evaluating the Utility of Stress Ulcer Prophylaxis in the Critically Ill Patient: A Clinical Scenario-Based Meta-Analysis. Pharmacotherapy. 2019 Mar;39(3):408-420. Available at: https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2172

    El-Kersh K, Jalil B, McClave SA, Cavallazzi R, Guardiola J, Guilkey K, Persaud AK, Furmanek SP, Guinn BE, Wiemken TL, Alhariri BC, Kellie SP, Saad M. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study. J Crit Care. 2018 Feb;43:108-113. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0883944117305294?via%3Dihub