What are the guidelines for stress ulcer prophylaxis in hospitalized patients?

Guidelines for Stress Ulcer Prophylaxis in Hospitalized Patients

Stress ulcer prophylaxis should only be given to hospitalized patients with specific risk factors for gastrointestinal bleeding, particularly mechanical ventilation >48 hours or coagulopathy, and should be discontinued when risk factors are no longer present. 1

Risk Assessment for Stress Ulcer Prophylaxis

High-Risk Patients (Prophylaxis Recommended)

• Patients with sepsis or septic shock who have risk factors for GI bleeding 1
• Patients requiring mechanical ventilation for >48 hours (OR = 15.6) 1, 2
• Patients with coagulopathy (OR = 4.3) 1, 2

Low-Risk Patients (Prophylaxis NOT Recommended)

• Patients without risk factors for GI bleeding 1
• Patients not requiring mechanical ventilation or without coagulopathy 1

Medication Selection

When stress ulcer prophylaxis is indicated:

• Either proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) can be used 1
• The 2016 Surviving Sepsis Campaign guidelines suggest a weak preference for PPIs over H2RAs (weak recommendation, low quality evidence) 1
• Consider potential risks of acid suppression:
  • Increased risk of ventilator-associated pneumonia (VAP) - H2RAs increase VAP risk by approximately 35% compared to sucralfate 1
  • Increased risk of Clostridioides difficile infection 3, 4

Number Needed to Treat (NNT)

• For patients with both respiratory failure and coagulopathy: NNT = 27 to prevent one clinically important bleeding event 1
• For patients without these risk factors: NNT = 1,000 1

Duration of Prophylaxis

• Continue prophylaxis only while risk factors persist 5
• Discontinue prophylaxis when:
  • Patient is extubated (if mechanical ventilation was the only risk factor)
  • Coagulopathy resolves
  • Patient is transferred out of ICU (if no ongoing risk factors) 5

Common Pitfalls to Avoid

1. Overuse in low-risk patients: 68.1% of ICU patients with no risk factors inappropriately receive prophylaxis 5
2. Failure to discontinue: 60.4% of patients continue on prophylaxis after ICU transfer and 31% are discharged home on these medications without indications 5
3. Ignoring potential adverse effects: Both PPIs and H2RAs may increase risk of pneumonia and C. difficile infections 3, 4
4. Not considering drug interactions: PPIs may have clinically relevant interactions with other medications (e.g., clopidogrel) 3

Monitoring

• Regularly assess for signs of GI bleeding
• Monitor for adverse effects of prophylactic medications
• Regularly reassess the need for continued prophylaxis as patient's condition changes

The evidence clearly demonstrates that stress ulcer prophylaxis should be targeted to specific high-risk populations rather than used routinely in all hospitalized or ICU patients. While prophylaxis reduces bleeding risk in high-risk patients, inappropriate use increases adverse effects without providing benefit.