Which of the following does not have a direct efficacy in preventing stress gastritis: Sucralfate, Proton pump inhibitors (PPIs), Enteral diet, or Histamine-2 (H2) receptor antagonists?

Efficacy of Agents in Preventing Stress Gastritis in ICU Patients

Enteral diet has not shown direct efficacy in preventing stress gastritis compared to pharmacological agents such as PPIs, H2 receptor antagonists, and sucralfate. 1

Comparison of Stress Ulcer Prophylaxis Options

Effective Agents

1. Proton Pump Inhibitors (PPIs)

   • Potently suppress gastric acid secretion
   • Recommended by the Society of Critical Care Medicine as a primary option for stress ulcer prophylaxis in high-risk critically ill patients 1
   • Achieve more rapid and sustained increase in gastric pH compared to H2RAs 2
   • Low-dose therapy (e.g., pantoprazole 40 mg IV daily) is preferred over high-dose therapy 1

2. Histamine-2 Receptor Antagonists (H2RAs)

   • Well-established efficacy in preventing stress ulcer bleeding in critically ill patients
   • Significantly reduce the risk of clinically important GI bleeding compared to placebo 1
   • May be associated with rapid tachyphylaxis (diminishing effect over time) 2
   • Recent cohort studies suggest they may have better outcomes than PPIs in some real-world settings 3

3. Sucralfate

   • Provides direct protective effects on the gastric mucosa
   • Typical odds ratio of 0.532 compared to H2-antagonists, indicating superior efficacy 1, 4
   • May provide additional protection when used with PPIs or H2RAs 1
   • Works by forming a protective barrier over damaged mucosa rather than altering gastric pH 5

Less Effective Agent

• Enteral Nutrition
  • While enteral nutrition provides some protection by maintaining mucosal blood flow, buffering gastric acid, and providing nutrients to support mucosal integrity, it is not considered a direct pharmacological stress ulcer prophylaxis agent 1
  • Patients with risk factors still benefit from pharmacological stress ulcer prophylaxis even when enterally fed 1
  • Does not have the same direct protective mechanisms as the pharmacological agents

Risk Factors for Stress-Related GI Bleeding

• Shock (particularly in patients on vasopressors)
• Coagulopathy
• Chronic liver disease
• Sepsis 1

Clinical Approach to Stress Ulcer Prophylaxis

1. Assess patient for risk factors (shock, coagulopathy, chronic liver disease, sepsis)
2. If high risk, initiate pharmacological prophylaxis with either:
   • PPI (first-line per current guidelines)
   • H2RA (acceptable alternative)
   • Consider adding sucralfate for additional protection 1
3. Monitor for signs of GI bleeding and potential adverse effects
4. Discontinue prophylaxis when risk factors resolve or critical illness is no longer evident 1

Important Considerations and Caveats

• Recent cohort studies suggest H2RAs may be associated with lower risks of GI bleeding and mortality compared to PPIs in real-world settings, contradicting some earlier recommendations 3
• Overuse of stress ulcer prophylaxis increases costs and potential harms, including C. difficile infection 1
• Mechanical ventilation is no longer considered an independent risk factor per the 2024 Society of Critical Care Medicine guidelines 1
• The choice between agents should consider patient-specific factors including renal and hepatic function and potential drug interactions 2