Which option is less effective for immediate prevention of stress gastritis: sucralfate, proton pump inhibitors (PPIs), enteral diet, or histamine-2 (H2) receptor antagonists?

From the Guidelines

Among the options for immediate prevention of stress gastritis, an enteral diet is the least effective standalone approach. While sucralfate, proton pump inhibitors (PPIs), and histamine-2 (H2) receptor antagonists all provide direct pharmacological protection against gastric acid damage, enteral feeding works through indirect mechanisms that take longer to establish protective effects. PPIs like pantoprazole and omeprazole are highly effective by irreversibly blocking acid production, while H2 blockers such as famotidine provide rapid but less sustained acid suppression 1. Sucralfate forms a protective barrier over damaged mucosa. Although enteral nutrition eventually helps maintain mucosal integrity by providing blood flow and nutrients to the gastric mucosa, it doesn't offer the immediate chemical protection needed in high-risk situations like critical illness, extensive burns, or mechanical ventilation.

Key Points to Consider

• The most recent guidelines suggest using either PPIs or H2RAs as first-line agents for stress ulcer prophylaxis (SUP) in critically ill adults with risk factors for clinically important stress-related upper gastrointestinal bleeding (UGIB) 1.
• Enteral nutrition is recommended as a complementary approach to pharmacological agents for SUP, rather than the primary preventive strategy 1.
• The choice between PPIs and H2RAs should be based on individual patient factors, as both have been shown to be effective in reducing the risk of UGIB, but with varying certainty of evidence 1.
• Sucralfate is also an effective option for SUP, particularly in patients at high risk of pneumonia, as it has been associated with a lower risk of pneumonia compared to PPIs and H2RAs 1.

Recommendations for Practice

• Pharmacological agents, such as PPIs or H2RAs, should be used as first-line therapy for stress gastritis prophylaxis in high-risk patients, with enteral nutrition serving as a complementary approach rather than the primary preventive strategy.
• The selection of a specific pharmacological agent should be based on individual patient factors, including the presence of risk factors for UGIB, the severity of illness, and the potential for adverse effects.
• Enteral nutrition should be initiated as soon as possible in critically ill patients, as it has been shown to reduce the risk of UGIB and improve outcomes 1.

From the Research

Stress Gastritis Prevention

The question of which option is less effective for immediate prevention of stress gastritis can be addressed by examining the efficacy of sucralfate, proton pump inhibitors (PPIs), enteral diet, and histamine-2 (H2) receptor antagonists.

• Sucralfate: According to 2, the guideline panel recommends against using sucralfate for stress ulcer prophylaxis, suggesting it is less effective compared to other options.
• Proton Pump Inhibitors (PPIs): Studies such as 2, 3, and 4 indicate that PPIs are effective in reducing the risk of clinically important gastrointestinal bleeding, making them a viable option for preventing stress gastritis.
• Enteral Diet: While enteral nutrition is beneficial for critically ill patients, its direct role in preventing stress gastritis is less clear. However, 5 suggests that among patients who received enteral nutrition, stress ulcer prophylaxis was associated with a decreased risk of clinically important GI bleeding, implying that an enteral diet might support the prevention of stress gastritis when used alongside other prophylactic measures.
• Histamine-2 (H2) Receptor Antagonists: Like PPIs, H2 receptor antagonists are used for stress ulcer prophylaxis and have been shown to reduce the risk of gastrointestinal bleeding, as indicated by 2, 3, and 4.

Comparison of Efficacy

Given the information from the studies, sucralfate stands out as the option that is recommended against by guidelines 2, suggesting it is less effective for the immediate prevention of stress gastritis compared to PPIs, H2 receptor antagonists, and potentially an enteral diet when used as part of a comprehensive approach to stress ulcer prophylaxis.