Which patients require stress ulcer prophylaxis (SUP) in hospitals?

From the Guidelines

Stress ulcer prophylaxis (SUP) in hospitals should be limited to critically ill adults with coagulopathy, shock, or chronic liver disease, as these factors likely increase the risk for clinically important stress-related upper gastrointestinal bleeding (UGIB) 1. The decision to provide SUP should be based on the presence of risk factors, and the preferred medications are proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) at low dosage regimens 1. Some key points to consider when deciding on SUP include:

• Enteral nutrition probably reduces UGIB risk, and SUP should be considered for critically ill adults with risk factors who are enterally fed 1
• SUP should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness 1
• Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing 1
• The use of either PPIs or H2RAs as first-line agents for SUP in critically ill adults with risk factors for clinically important stress-related UGIB is recommended 1 It is essential to weigh the benefits and risks of SUP, as unnecessary use can increase the risks of hospital-acquired pneumonia, Clostridioides difficile infection, and drug interactions 1. The rationale for SUP is that critically ill patients have reduced gastric mucosal blood flow and defense mechanisms, leading to increased risk of stress-related mucosal damage, and the presence of coagulopathy, shock, or chronic liver disease further increases this risk 1. Therefore, SUP should be provided to critically ill adults with coagulopathy, shock, or chronic liver disease, and discontinued when the risk factors are no longer present or at hospital discharge unless there's another indication for acid suppression 1.

From the Research

Patients Requiring Stress Ulcer Prophylaxis (SUP)

The following patients are considered to be at high risk and may require stress ulcer prophylaxis (SUP) in hospitals:

• Critically ill patients in the ICU, particularly those with a high risk of clinically important gastrointestinal bleeding (>4%) 2
• Patients receiving invasive mechanical ventilation, especially those expected to be ventilated for ≥ two days 3
• Patients with coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition 2
• Patients with two or more of the following conditions: mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock 2

Risk Factors for Gastrointestinal Bleeding

The risk factors for gastrointestinal bleeding in critically ill patients include:

• Coagulopathy
• Chronic liver disease
• Mechanical ventilation
• Acute kidney injury
• Sepsis
• Shock
• Lack of enteral nutrition 2, 4

Recommendations for SUP

The recommendations for SUP in critically ill patients are:

• Use of gastrointestinal bleeding prophylaxis in patients at high risk of clinically important gastrointestinal bleeding (>4%) 2
• Use of a proton pump inhibitor (PPI) rather than a histamine-2 receptor antagonist (H2RA) 2
• Discontinuation of SUP when patients no longer require mechanical ventilation, are no longer nil per os (NPO), or are discharged from the ICU 3