From the Guidelines
Proton pump inhibitors (PPIs) are the recommended gastrointestinal protection for patients on high-dose or prolonged corticosteroid treatment. When considering gastrointestinal protection for patients on corticosteroids, it's essential to weigh the risks and benefits, prioritizing morbidity, mortality, and quality of life as outcomes. The use of PPIs is supported by studies such as 1, which highlights the importance of careful monitoring and management of patients on steroid therapy, particularly those at high risk of gastrointestinal side effects. Standard options for PPIs include omeprazole 20mg daily, pantoprazole 40mg daily, or esomeprazole 20mg daily, taken in the morning before breakfast. This prophylaxis should be initiated when starting corticosteroid therapy at doses equivalent to ≥20mg prednisone daily for more than 4 weeks, or for shorter durations in patients with additional risk factors such as concurrent NSAID use, history of peptic ulcer disease, or advanced age. Some key points to consider when prescribing PPIs for gastrointestinal protection in patients on corticosteroids include:
- The importance of reducing gastric acid production to protect the gastric mucosa from the increased risk of ulceration associated with corticosteroids
- The potential for corticosteroids to impair prostaglandin synthesis and reduce mucus production in the stomach, compromising the natural protective barrier of the gastric lining
- The need to continue gastroprotection for the duration of corticosteroid therapy and taper when the steroid dose is reduced below the risk threshold
- The consideration of H2-receptor antagonists like ranitidine 150mg twice daily as an alternative if PPIs are not tolerated, though they may be less effective. It's also worth noting that while older studies like 1 support the use of H2-receptor blockers or proton pump inhibitors for preventive treatment of gastrointestinal complications, more recent evidence prioritizes the use of PPIs due to their superior efficacy in reducing gastric acid production.
From the FDA Drug Label
Gastric irritation may be reduced if taken before, during, or immediately after meals or with food or milk... administration of antacids between meals to help prevent peptic ulcers. Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since they may increase the risk of a perforation
The recommended gastrointestinal protection for patients on high-dose or prolonged steroid treatment is the administration of antacids between meals to help prevent peptic ulcers. However, it is also important to note that steroids should be used with caution in active or latent peptic ulcers.
- Key considerations include:
From the Research
Gastrointestinal Protection for Patients on Steroid Treatment
The use of steroids, particularly at high doses or for prolonged periods, can increase the risk of gastrointestinal complications.
- Patients on steroid treatment are at a higher risk of developing gastrointestinal ulcers and bleeding due to the suppression of the immune system and the reduction of protective prostaglandins in the stomach lining.
- The recommended gastrointestinal protection for these patients is a topic of interest, with various studies comparing the efficacy of different acid-suppressing agents.
Comparison of Acid-Suppressing Agents
Studies have compared the effectiveness of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) in preventing gastrointestinal complications in patients on steroid treatment.
- A study published in 2001 3 found that PPIs, such as omeprazole, were more effective than H2RAs, such as ranitidine, in healing gastric and duodenal ulcers in patients continuing non-steroidal anti-inflammatory drugs (NSAIDs).
- Another study published in 2012 4 compared the effects of a H2RA (famotidine) and a PPI (omeprazole) in patients with bleeding gastroduodenal ulcers and found no significant difference in the hemostatic effect between the two groups.
- However, a retrospective cohort study published in 2021 5 found that PPI use was associated with a higher risk of in-hospital mortality, gastrointestinal bleeding, and pneumonia compared to H2RA use in critically ill patients with sepsis.
- A similar study published in 2021 6 found that PPIs had a higher 90-day mortality rate compared to H2RAs, but no significant difference in the risk of clinically important gastrointestinal bleeding.
Proton Pump Inhibitors vs. Histamine-2 Receptor Antagonists
The choice between PPIs and H2RAs for gastrointestinal protection in patients on steroid treatment depends on various factors, including the patient's individual risk factors, the severity of the steroid treatment, and the presence of other comorbidities.
- PPIs may be more effective in reducing the risk of gastrointestinal ulcers and bleeding, but they may also be associated with a higher risk of adverse events, such as pneumonia and Clostridioides difficile infection.
- H2RAs, on the other hand, may be safer and more effective in certain patient populations, such as those with sepsis or high disease severity.
- A study published in 1998 7 found that treatment with omeprazole reduced the effect of ranitidine in H. pylori-negative patients, suggesting that the choice of acid-suppressing agent may depend on the patient's H. pylori status.