Does a hospitalized patient on a diet require gastrointestinal (GI) prophylaxis?

From the Guidelines

Hospitalized patients on a diet alone do not typically require gastrointestinal (GI) prophylaxis. GI prophylaxis, such as acid-suppressive medications like proton pump inhibitors (PPIs) or H2 receptor antagonists, should be reserved for specific high-risk patients, as recommended by the Surviving Sepsis Campaign guidelines 1. These include patients with mechanical ventilation for more than 48 hours, coagulopathy, history of GI bleeding, severe burns, traumatic brain injury, spinal cord injury, or those on high-dose corticosteroids.

Key Points to Consider

• The guidelines suggest using either proton pump inhibitors or histamine-2 receptor antagonists when stress ulcer prophylaxis is indicated 1.
• The duration of GI prophylaxis should be limited to the period of risk, with reassessment for discontinuation when risk factors resolve.
• Unnecessary GI prophylaxis can lead to adverse effects including Clostridioides difficile infection, pneumonia, vitamin and mineral deficiencies, and kidney injury.
• A study from 2017 found that the incidence of clinically important GI bleeding was 2.6% in critically ill patients 1.

High-Risk Patients

• Patients with mechanical ventilation for more than 48 hours
• Patients with coagulopathy
• Patients with a history of GI bleeding
• Patients with severe burns
• Patients with traumatic brain injury
• Patients with spinal cord injury
• Patients on high-dose corticosteroids For patients who do require prophylaxis, options include pantoprazole 40mg IV/PO daily, omeprazole 20mg PO daily, or famotidine 20mg IV/PO twice daily, as suggested by the guidelines 1. The practice of routine stress ulcer prophylaxis for all hospitalized patients is not supported by evidence and represents low-value care that may cause more harm than benefit, as also noted in other studies 1.

From the Research

Gastrointestinal Prophylaxis for Hospitalized Patients on a Diet

• The need for gastrointestinal (GI) prophylaxis in hospitalized patients on a diet is not universally required, but rather depends on the patient's specific risk factors and conditions 2, 3, 4, 5, 6.
• For patients with upper gastrointestinal bleeding, enteral nutrition is considered the best stress ulcer prophylaxis, and the concomitant use of histamine-2 receptor blockers or proton-pump inhibitors may be harmful 2.
• In patients at high risk of GI bleeding, such as those with acute coronary syndromes, prophylactic treatment with pantoprazole may reduce the risk of GI bleeding 3.
• However, for non-critically ill patients, routine use of acid suppressant medications for prophylaxis is unnecessary, and anticoagulation appears to be the most important risk factor for nosocomial GI bleeding 4.
• A prior intensive care unit stay and mechanical ventilation are independent risk factors for the onset of bleeding in hospitalized patients 5.
• The use of gastrointestinal bleeding prophylaxis in critically ill patients should be based on individual patient risk factors, with a weak recommendation for using prophylaxis in patients at high risk (>4%) of clinically important GI bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%) 6.

Risk Factors for GI Bleeding

• Risk factors for GI bleeding in hospitalized patients include:
  • Anticoagulation therapy 4
  • Prior intensive care unit stay 5
  • Mechanical ventilation 5
  • Coagulopathy 6
  • Chronic liver disease 6
  • Receipt of mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock 6

Prophylaxis Recommendations

• For critically ill patients at high risk of GI bleeding, a weak recommendation is made for using gastrointestinal bleeding prophylaxis, with a preference for proton pump inhibitors (PPIs) over histamine-2 receptor antagonists (H2RAs) 6.
• Sucralfate is not recommended for use in critically ill patients 6.