Stress Ulcer Prophylaxis - a review

PROPHYLAXIS

Indications — Based upon randomized trials and guideline recommendations from the American Society of Health System Pharmacists, stress ulcer prophylaxis should be administered to all critically ill patients who are at high risk for gastrointestinal (GI) bleeding (1999).

ASHP Guidelines 1999 (great year by the way, the year I graduated pharmacy school!)
• Prophylaxis appropriate for patients admitted to the ICU with one or more of the following: 

  • Mechanical ventilation >48 hours
  • Coagulopathy
  • GI ulcer or bleeding within the past year
  • Glasgow Coma Score </= 10
  • Thermal injury >35% BSA
  • Partial hepatectomy
  • Multiple trauma
  • Transplantation patients in the ICU perioperatively
  • Hepatic failure
  • Spinal cord injury
  • Patients with at least 2 of the following: 
    • Sepsis 
    • ICU stay >1 week 
    • Occult GI bleeding >/= 6 days 
    • Steroid therapy with >250 mg hydrocortisone or equivalent per day 

(ASHP Commission on Therapeutics. Am J Health-Syst Pharm 1999; 56:347-379)

  • Choice among antacids, histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP should be made on institution-specific basis
  • Do not include recommendations for proton pump inhibitors (PPIs) 
  • SUP is not recommended for adult patients in non-ICU settings 
    • (B) for patients with <2 risk factors 
    • (D) for patients with >/= 2 risk factors 

Possible Complications with PPIs 

  • Headache, diarrhea, constipation, abdominal pain, nausea 
  • Nutritional deficiencies – magnesium, calcium, iron, B-12 
  • Fracture risk 
  • Drug interactions 
  • Infection 
    • Pneumonia 
    • C. diff infection
    • Spontaneous bacterial peritonitis 
    • Interstitial nephritis 
    • Rebound hypersecretion

Possible Complications with H2RAs 

  • CNS adverse effects 
  • Thrombocytopenia 
  • Fracture risk 
  • CYP-450 DDIs (cimetidine) 
  • Infection 
    • Pneumonia 
    • CDI 

Which Agent Should be Used When SUP Indicated? 

  • H2RAs over antacids and sucralfate 
  • H2RAs vs. PPIs? 
  • PPIs more potent inhibitors of acid secretion 
  • No tolerance with PPIs (tolerance with H2RAs)
  • PPIs superior to H2RAs in other settings 
  • SUP is less dependent on acid suppression than in the setting of rebleeding prevention – are H2RAs sufficient? 

What is next?  The guidelines are presently in review and should be released pretty soon:

ASHP Therapeutic Guidelines

ASHP's professional policies contain varying levels of detail. Policy positions are short pronouncements on one aspect of practice. Statements express basic philosophy, and guidelines (including what were formerly called "technical assistance bulletins") offer programmatic advice. Therapeutic position statements are concise responses to specific therapeutic issues, and therapeutic guidelines are thorough, evidence-based recommendations on drug use.

Note: All ASHP therapeutic guidelines are in PDF.

Gastrointestinal Stress Ulcer Prophylaxis       New    In process      Q2 2014

I will definitely have to revisit later on in the year.

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