What is the recommended stress ulcer prophylaxis for critically ill patients in the Intensive Care Unit (ICU)?

From the Guidelines

Critically ill patients in the ICU with risk factors for gastrointestinal bleeding should receive stress ulcer prophylaxis with either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) at low dosage regimens. The most recent and highest quality study, published in 2024 1, suggests that PPIs or H2RAs should be used as first-line agents for stress ulcer prophylaxis in critically ill adults with risk factors for clinically important stress-related UGIB. Specifically, intravenous pantoprazole 40 mg daily or oral pantoprazole 40 mg daily (if enteral route is available) is commonly used. Other PPI options include omeprazole 40 mg daily or esomeprazole 40 mg daily. Histamine-2 receptor antagonists (H2RAs) such as famotidine 20 mg twice daily are an alternative when PPIs are contraindicated.

Key Points to Consider

• Risk factors for gastrointestinal bleeding in critically ill patients include coagulopathy, shock, and chronic liver disease, as identified in the 2024 study 1.
• Enteral nutrition probably reduces the risk of clinically important stress-related UGIB in critically ill adults, as suggested by the 2024 study 1.
• Prophylaxis should be continued throughout the ICU stay while risk factors persist, but should be reassessed daily and discontinued when no longer needed to prevent complications like Clostridioides difficile infection or pneumonia.
• The 2017 study 1 also recommends stress ulcer prophylaxis for patients with sepsis or septic shock who have risk factors for gastrointestinal bleeding, but the 2024 studies 1 provide more recent and specific guidance on the use of PPIs and H2RAs.

Recommendations for Practice

• Use either PPIs or H2RAs as first-line agents for stress ulcer prophylaxis in critically ill adults with risk factors for clinically important stress-related UGIB, as recommended by the 2024 study 1.
• Discontinue stress ulcer prophylaxis when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness, as suggested by the 2024 study 1.

From the Research

Stress Ulcer Prophylaxis in ICU

• Stress ulcer prophylaxis (SUP) is recommended in high-risk patients, especially those mechanically ventilated > 48 h and those with a manifest coagulopathy 2.
• Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) prevent GI bleeding in critically ill patients in the ICU, with PPI being more effective 2, 3.
• However, the routine use of pharmacological SUP does not reduce overall mortality in ICU patients, and may be associated with potential harm such as an increased risk of infectious complications 2, 4.

Risk Factors and Indications

• Consistent risk factors for gastrointestinal bleeding have been identified, but indications for SUP vary considerably 4.
• Patients at risk of stress ulcer-related bleeding are most likely to benefit from prophylaxis, and healthcare professionals should continue to evaluate risk and assess the need for stress ulcer-related prophylaxis 5.
• The use of SUP is not well justified by current evidence for routine prophylaxis against stress ulcers in the ICU, and should be considered on a case-by-case basis 4, 5.

Alternatives and Considerations

• Alternatives to PPI prophylaxis include H2RA and/or sucralfate 2.
• Special populations such as patients with liver cirrhosis may have an increased mortality rate if treated with PPI, and the agent of choice and dose should be carefully considered 2.
• The balance between benefits and harms of SUP is unknown, and clinical equipoise exists, highlighting the need for high-quality randomized controlled trials and systematic reviews assessing benefits and harms of SUP in ICU patients 4.