From the Guidelines
Proton Pump Inhibitors (PPIs) are primarily indicated in the ICU for stress ulcer prophylaxis in high-risk patients to prevent gastrointestinal bleeding, as recommended by the most recent guidelines 1. The use of PPIs in the ICU is supported by the Society of Critical Care Medicine and American Society of Health-System Pharmacists guideline for the prevention of stress-related gastrointestinal bleeding in critically ill adults, which suggests that all critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB 1. Some key points to consider when using PPIs in the ICU include:
- Initiating PPIs for ICU patients with specific risk factors such as coagulopathy, shock, and chronic liver disease, as identified by the guidelines 1
- Using low-dose PPI therapy, defined as a daily dose of less than or equal to 40mg esomeprazole, omeprazole, or pantoprazole, as recommended by the guidelines 1
- Discontinuing PPIs when critical illness is no longer evident or the risk factor(s) is no longer present, despite ongoing critical illness, to minimize potential adverse effects 1
- Considering the potential risks and benefits of PPIs, including the risk of Clostridioides difficile infection, pneumonia, hypomagnesemia, and vitamin B12 deficiency, as noted in the guidelines 1 Overall, the use of PPIs in the ICU should be guided by the most recent and highest-quality evidence, with a focus on minimizing morbidity, mortality, and improving quality of life for critically ill patients.
From the Research
Indications for Proton Pump Inhibitors (PPIs) in the Intensive Care Unit (ICU)
- The primary indication for PPIs in the ICU is for the prevention of upper gastrointestinal bleeding in critically ill patients 2, 3, 4, 5, 6.
- PPIs are commonly used for stress ulcer prophylaxis in mechanically ventilated patients and those at high risk of clinically important gastrointestinal bleeding 2, 5, 6.
- The use of PPIs is recommended for patients at high risk (>4%) of clinically important gastrointestinal bleeding, while a weak recommendation is made against using prophylaxis in patients at lower risk of clinically important bleeding (≤4%) 6.
Risk Factors and Patient Selection
- Patients with coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock are considered to be at higher bleeding risk 6.
- Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis 6.
Comparison with Histamine-2 Receptor Antagonists (H2RAs)
- PPIs are suggested over H2RAs for stress ulcer prophylaxis due to their potential to reduce the risk of bleeding more effectively 5, 6.
- However, the overall rate of clinically important gastrointestinal bleeding is low, and the use of PPIs may be associated with increased risk of hospital mortality and other adverse effects 5.