What is the recommended regimen for inpatient Gastrointestinal (GI) prophylaxis?

Inpatient GI Prophylaxis: Recommended Regimen

For critically ill inpatients at high risk of gastrointestinal bleeding (mechanical ventilation >48 hours, coagulopathy, severe liver disease, sepsis/shock, or history of GI bleeding), initiate proton pump inhibitor (PPI) prophylaxis immediately upon ICU admission, using intravenous pantoprazole 40 mg daily or equivalent PPI, and continue until risk factors resolve. 1, 2

Risk Stratification for Prophylaxis

High-risk patients (>4% bleeding risk) who require prophylaxis include: 1, 2, 3

• Mechanical ventilation for >48 hours 1, 2
• Coagulopathy (strongest predictor with OR 4.3) 1, 2
• Severe liver disease (MELD ≥35) 2
• Sepsis or septic shock 1
• Acute kidney injury 1
• History of GI bleeding or peptic ulcer disease 2
• Multiple organ failure 1
• Major vascular or abdominal surgery 2

Low-risk patients (≤4% bleeding risk) do not require routine prophylaxis. 3 The American College of Critical Care Medicine specifically recommends against prophylaxis in patients without risk factors. 1

Medication Selection and Dosing

PPIs are preferred over H2-receptor antagonists (H2RAs) for stress ulcer prophylaxis in high-risk patients. 2, 3 The 2020 BMJ guideline and recent consensus data demonstrate that PPIs probably reduce bleeding risk more than H2RAs (moderate certainty evidence). 3

Specific Regimens:

For critically ill patients unable to take oral medications:

• Intravenous pantoprazole 40 mg daily (preferred agent) 1, 2
• Alternative: IV esomeprazole or lansoprazole 4

For patients with active upper GI bleeding requiring endoscopic therapy:

• Loading dose: 80 mg IV bolus 5
• Continuous infusion: 8 mg/hour for 72 hours 5
• Transition to oral: twice-daily PPI for 14 days, then once-daily 5

For stable patients able to take oral medications:

• Oral PPI once daily (pantoprazole 40 mg, omeprazole 40 mg, or equivalent) 1

Timing and Duration

Initiate prophylaxis immediately upon ICU admission for high-risk patients. 1, 2 The evidence shows stress-related gastric ulcers can develop within 24-48 hours of critical illness onset. 1

Continue prophylaxis as long as risk factors persist and critical illness continues. 1, 2 Discontinue when:

• Sepsis resolves and patient tolerates enteral nutrition 1
• Mechanical ventilation discontinued and coagulopathy corrected 2
• Risk factors no longer present 2

Reevaluate need for prophylaxis daily based on risk factor resolution. 2

Important Caveats and Monitoring

Monitor for signs of GI bleeding from admission: melena, hematemesis, hemoglobin drop. 1, 2 Mortality is significantly higher in critically ill patients who develop bleeding from stress ulcers (48.5%) compared to those who do not bleed (9.1%). 1

Be aware of PPI-associated risks: 3

• Possible increased risk of pneumonia (low certainty evidence) 3
• No significant effect on mortality or length of stay (moderate certainty) 3
• Long-term risks include C. difficile infection, community-acquired pneumonia, bone fractures, and micronutrient deficiencies 5

Use the lowest effective dose and shortest duration necessary. 5

Special Populations

For patients with severe liver disease (MELD 35) and sepsis:

• IV pantoprazole 40 mg daily is preferred due to consistent acid suppression and reduced hepatic metabolism concerns 1
• PPIs are preferred over H2RAs in this population 1

For neurocritical care patients:

• Avoid H2RAs due to risk of encephalopathy and drug interactions with anticonvulsants 6
• Use PPIs as first-line prophylaxis 6

For patients on antiplatelet therapy with history of ulcer bleeding:

• Continue PPI prophylaxis with single or dual antiplatelet therapy 5
• PPIs plus aspirin reduce rebleeding rates versus clopidogrel alone (RR 0.07) 5

H2-Receptor Antagonists as Alternative

H2RAs (ranitidine, famotidine) may be used when PPIs are unavailable or contraindicated, though they are less effective than PPIs at reducing bleeding risk. 3 Both agents reduce clinically important bleeding compared to placebo (moderate certainty), but PPIs demonstrate superior efficacy. 3

Do not use sucralfate for stress ulcer prophylaxis (strong recommendation against). 3