Should an 81-year-old female patient with sepsis, mechanical ventilation, and shock receive pantoprazole (Protonix) 40 mg intravenously (IV) daily as stress ulcer prophylaxis (SUP)?

Stress Ulcer Prophylaxis for Mechanically Ventilated Patient with Sepsis and Shock

This patient should receive pantoprazole 40 mg IV daily as SUP to reduce the risk for clinically important upper gastrointestinal bleeding because she is mechanically ventilated and in shock. 1

Risk Assessment for Stress Ulcer Bleeding

JM presents with multiple high-risk factors for developing stress-related gastrointestinal bleeding:

• Mechanical ventilation (primary risk factor)
• Shock/vasopressor use (primary risk factor)
• Advanced age (81 years)
• Multiple comorbidities (diabetes mellitus, COPD)
• Sepsis secondary to pneumonia

According to the 2024 Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) guidelines, patients with coagulopathy, shock, or chronic liver disease should be considered at risk for clinically important upper gastrointestinal bleeding (UGIB) 2. The guidelines specifically recommend stress ulcer prophylaxis (SUP) for critically ill adults with these risk factors 2.

Evidence Supporting Pantoprazole Use

The most recent and highest quality evidence comes from the 2024 REVISE trial published in the New England Journal of Medicine, which demonstrated that:

• Pantoprazole 40 mg IV daily significantly reduced clinically important upper GI bleeding compared to placebo (1.0% vs 3.5%, hazard ratio 0.30) in mechanically ventilated patients 1
• This reduction in bleeding was achieved without increasing the risk of pneumonia or C. difficile infection
• The number needed to treat to prevent one episode of clinically important bleeding was approximately 40 patients

Enteral Nutrition and SUP

While JM is receiving enteral nutrition, this alone is insufficient protection:

• The 2024 SCCM/ASHP guidelines suggest using SUP for critically ill adults who are enterally fed and possess one or more risk factors for clinically important stress-related UGIB 2
• JM has multiple risk factors (mechanical ventilation and shock), making her a candidate for SUP despite receiving enteral nutrition

Medication Selection and Administration

• Either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) are acceptable first-line agents according to the guidelines 2
• Pantoprazole 40 mg IV daily is an appropriate low-dose regimen for SUP as recommended by the guidelines 2
• The IV route is appropriate given her critical condition and mechanical ventilation

Duration of Therapy

SUP should be continued while risk factors persist:

• Continue pantoprazole while JM remains mechanically ventilated and/or on vasopressors
• Consider discontinuation when risk factors resolve (extubation, hemodynamic stability)
• Discontinue before ICU transfer to prevent inappropriate continuation 2

Monitoring Considerations

• Monitor for overt signs of GI bleeding (hematemesis, melena, hematochezia)
• Track hemoglobin levels for occult bleeding
• Be vigilant for potential adverse effects including pneumonia and C. difficile infection, although the REVISE trial showed no significant increase in these complications 1

The evidence strongly supports the use of pantoprazole for SUP in this high-risk patient to reduce the likelihood of clinically important upper GI bleeding, which can significantly impact morbidity in critically ill patients.