Indications for PPI Inhibitors in ICU Patients
Proton pump inhibitors (PPIs) should be administered to critically ill ICU patients with risk factors for stress-related upper gastrointestinal bleeding (UGIB), specifically those with coagulopathy, shock, or chronic liver disease. 1
Risk Factors for Stress-Related UGIB in ICU Patients
- Coagulopathy is associated with an increased absolute risk of stress-related UGIB of 4.8% (95% CI, 2.6–8.6) 1
- Shock is associated with an increased absolute risk of stress-related UGIB of 2.6% (95% CI, 1.2–5.4) 1
- Chronic liver disease is associated with an increased absolute risk of stress-related UGIB of 7.6% (95% CI, 3.3–17.6) 1
- Mechanical ventilation alone is not considered an independent risk factor for UGIB and does not necessitate stress ulcer prophylaxis (SUP) 1
Role of Enteral Nutrition in Stress Ulcer Prophylaxis
- Enteral nutrition (EN) reduces the risk of clinically important stress-related UGIB in critically ill adults 1
- Enteral nutrition is associated with a decreased absolute risk of stress-related UGIB of 0.3% (95% CI, 0.1–0.7) 1
- However, even patients receiving enteral nutrition should receive SUP if they have one or more risk factors for clinically important stress-related UGIB 1
- For patients who are enterally fed but at low risk for UGIB, SUP is not recommended 1
Medication Selection for Stress Ulcer Prophylaxis
- Either PPIs or histamine-2 receptor antagonists (H2RAs) are recommended as first-line agents for SUP in critically ill adults with risk factors 1
- PPIs have been shown to reduce clinically important UGIB (relative risk 0.52; 95% CI, 0.30–0.81) 1
- While PPIs may be more effective than H2RAs at preventing UGIB, there is uncertainty regarding their influence on mortality in patients with high severity of illness 1
- For patients with acute liver failure, H2 blocking agents or PPIs are recommended for prophylaxis of acid-related GI bleeding 1
Administration Considerations
- Either enteral or intravenous routes can be used when administering SUP 1
- Low-dose SUP should be administered rather than high-dose SUP 1
- "Low-dose" PPI therapy is defined as a daily dose of ≤40mg esomeprazole, omeprazole, or pantoprazole and ≤30mg lansoprazole 1
- "Low-dose" H2RA therapy is defined as a daily dose of ≤40mg famotidine, ≤150mg IV ranitidine, ≤300mg enteral ranitidine, and ≤1200mg cimetidine 1
Duration of Therapy
- SUP should be discontinued when critical illness is no longer evident or when risk factors are no longer present despite ongoing critical illness 1
- Discontinuation of SUP before transfer out of the ICU is necessary to prevent inappropriate prescribing 1
- For patients already on SUP before ICU admission, the indications should be reviewed and consideration made for discontinuing or changing to the preferred agent 1
Potential Risks and Considerations
- Concurrent administration of SUP with enteral nutrition may increase pneumonia risk 1
- Some studies suggest PPIs may be associated with increased risk of Clostridioides difficile-associated diarrhea (CDAD) 2, 3
- However, the benefits of preventing clinically important UGIB in high-risk patients outweigh these potential risks 1, 4
- SUP is not recommended for general medicine patients outside the ICU without specific risk factors 5
Special Populations
- In neurocritical care patients, SUP is recommended to reduce clinically important stress-related UGIB 1
- These patients may be at additional risk due to physiologic changes resulting in hypersecretion of gastric acid 1
By following these evidence-based recommendations, clinicians can appropriately identify ICU patients who would benefit from PPI therapy while minimizing unnecessary medication use and potential adverse effects.