What is the recommended prophylactic therapy for stress-related mucosal disease (SRMD) gastritis in critically ill patients?

Prophylactic Therapy for Stress-Related Mucosal Disease (SRMD) in Critically Ill Patients

Either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) should be used as first-line agents for stress ulcer prophylaxis in critically ill patients with risk factors for clinically important stress-related upper gastrointestinal bleeding. 1

Risk Factors for SRMD

The decision to initiate stress ulcer prophylaxis should be based on the presence of specific risk factors:

• High-risk factors:

  • Coagulopathy
  • Shock
  • Chronic liver disease 1
  • Sepsis or septic shock 1

• Important note: Mechanical ventilation alone is no longer considered a definitive risk factor for SRMD according to the most recent guidelines 1

• Patients without risk factors should not receive prophylaxis 1

Medication Selection

When choosing between PPIs and H2RAs:

• Both medication classes are considered acceptable first-line options 1
• The 2024 SCCM/ASHP guideline suggests either PPIs or H2RAs as first-line agents (conditional recommendation, moderate certainty of evidence) 1
• Earlier guidelines (2016 Surviving Sepsis Campaign) had suggested PPIs over H2RAs (grade 2D), but this preference has been revised in more recent guidelines 1
• Network meta-analysis shows that compared to H2RAs, PPIs:
  • Reduce clinically important upper GI bleeding (RR 0.53; 95% CI 0.34-0.83)
  • May be associated with slightly increased mortality (RR 1.05; 95% CI 1-1.10) 1

Dosing Recommendations

Low-dose regimens are recommended (good practice statement) 1:

• For PPIs:

  • ≤40mg daily of esomeprazole, omeprazole, or pantoprazole
  • ≤30mg daily of lansoprazole

• For H2RAs:

  • ≤40mg daily of famotidine
  • ≤150mg IV daily or ≤300mg enteral daily of ranitidine
  • ≤1200mg daily of cimetidine

Route of Administration

• Either enteral or intravenous routes are acceptable (conditional recommendation, low certainty of evidence) 1
• The route should be selected based on the patient's clinical status and ability to tolerate enteral medications

Duration of Therapy

• Prophylaxis should be discontinued when:

  • Critical illness is no longer evident, OR
  • Risk factors are no longer present 1

• Prophylaxis should be discontinued before transfer out of the ICU to prevent inappropriate prescribing (good practice statement) 1

Special Considerations

Enteral Nutrition

• Enteral nutrition likely reduces UGIB risk but may not completely eliminate the need for pharmacologic prophylaxis in high-risk patients 1
• For patients who are enterally fed and have risk factors for SRMD, prophylaxis is still recommended 1

Potential Adverse Effects

• PPIs and H2RAs may be associated with:
  • Increased risk of Clostridioides difficile infection 2
  • Potential increased risk of pneumonia (particularly with higher gastric pH) 1
  • Potential for drug interactions (consider in patients on multiple medications) 3

Implementation Algorithm

1. Assess risk factors on ICU admission
2. Initiate prophylaxis only if risk factors are present
3. Select agent (PPI or H2RA) based on:
   • Patient-specific factors (renal/hepatic function)
   • Potential drug interactions
   • Institutional formulary
4. Use low-dose regimen
5. Reassess daily for continued need
6. Discontinue when risk factors resolve or before ICU transfer

Common Pitfalls to Avoid

• Providing prophylaxis to all ICU patients regardless of risk factors
• Continuing prophylaxis after risk factors have resolved
• Using high-dose regimens unnecessarily
• Failing to discontinue prophylaxis upon ICU transfer
• Overlooking potential drug interactions with PPIs or H2RAs

By following these evidence-based recommendations, clinicians can appropriately select patients who will benefit from SRMD prophylaxis while minimizing unnecessary medication use and potential adverse effects.