From the Guidelines
Gastrointestinal prophylaxis is recommended for critically ill adults with coagulopathy, shock, or chronic liver disease, as well as those with other risk factors for stress-related gastrointestinal bleeding, using either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) as first-line agents. The latest guidelines from the Society of Critical Care Medicine and the American Society of Health-System Pharmacists suggest that critically ill adults with these risk factors should be considered for stress ulcer prophylaxis to reduce the occurrence of clinically important stress-related upper gastrointestinal bleeding (UGIB) 1.
Patient Selection
The following patients should be considered for GI prophylaxis:
- Critically ill adults with coagulopathy, shock, or chronic liver disease
- Those with other risk factors for stress-related UGIB, such as mechanical ventilation, severe burns, or traumatic brain injury
- Patients who are enterally fed and possess one or more risk factor(s) for clinically important stress-related UGIB
First-Line Agents
First-line agents for stress ulcer prophylaxis include:
- PPIs, such as pantoprazole or omeprazole
- H2RAs, such as famotidine These agents work by raising gastric pH above 4, which inhibits pepsin activity and reduces mucosal damage caused by acid 1.
Initiation and Continuation
Prophylaxis should be initiated promptly upon ICU admission for high-risk patients and continued until risk factors resolve or the patient begins oral intake. It's essential to reassess the need for prophylaxis daily, as unnecessary continuation increases the risk of complications, including Clostridioides difficile infection, pneumonia, and hypomagnesemia. For patients on enteral nutrition, prophylaxis may still be needed, as tube feeds alone may not provide sufficient protection against stress ulceration in high-risk patients 1.
Key Considerations
- Enteral nutrition can reduce the risk of stress-related UGIB, but may not eliminate the need for prophylaxis in high-risk patients
- The choice between PPIs and H2RAs should be based on individual patient factors and clinical judgment
- Prophylaxis should be tailored to the individual patient's risk factors and clinical status, and should be re-evaluated regularly to minimize the risk of adverse effects 1.
From the Research
GI Prophylaxis Recommendations
- The use of gastrointestinal bleeding prophylaxis in critically ill patients is recommended for those at high risk (>4%) of clinically important gastrointestinal bleeding 2.
- A weak recommendation is made for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk, and a weak recommendation is made for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%) 2.
- Proton pump inhibitors (PPIs) are suggested over histamine-2 receptor antagonists (H2RAs) for GI prophylaxis, although the recommendation is weak 2.
- Sucralfate is not recommended for GI prophylaxis, with a strong recommendation against its use 2.
Comparison of PPIs and H2RAs
- PPIs and H2RAs have been shown to reduce the risk of clinically important bleeding in critically ill patients, with PPIs being more effective than H2RAs 3.
- PPIs may increase the risk of pneumonia, although the certainty of this effect is low 2, 3.
- There is no significant difference in the risk of mortality, length of hospital stay, or other important outcomes between PPIs and H2RAs 2, 3.
Patient Selection and Risk Factors
- Patients at higher risk of bleeding, such as those with coagulopathy, chronic liver disease, or receiving mechanical ventilation, may benefit from GI prophylaxis 2.
- The rate of GI prophylaxis in patients starting nonsteroidal anti-inflammatory drugs (NSAIDs) is low, with most patients receiving H2RAs despite evidence that they offer insufficient protection 4.
- Individual patient values, risk of bleeding, and other factors such as medication availability should be considered when deciding whether to use GI prophylaxis 2.