Stress Ulcer Prophylaxis: Recommended Regimen
Initiate stress ulcer prophylaxis immediately upon ICU admission with either proton pump inhibitors (PPIs) or H2-receptor antagonists (H2RAs) in patients with mechanical ventilation >48 hours or coagulopathy; withhold prophylaxis in patients lacking these risk factors. 1, 2
Risk Stratification: Who Requires Prophylaxis
High-Risk Patients (Treat These)
- Mechanical ventilation >48 hours is the strongest predictor with an odds ratio of 15.6 (p < 0.001) for clinically important gastrointestinal bleeding 3, 2
- Coagulopathy carries an odds ratio of 4.3 (p < 0.001) for stress ulcer bleeding 3, 2
- Combined risk: Patients with both respiratory failure and coagulopathy have a 3.7% bleeding risk, requiring treatment of only 27 patients to prevent one bleeding event 3, 2
- Severe sepsis or septic shock, particularly when combined with mechanical ventilation or coagulopathy 1, 2
Low-Risk Patients (Do NOT Treat These)
- Patients without respiratory failure or coagulopathy have only a 0.1% bleeding risk, requiring treatment of 1,000 patients to prevent one bleeding event—prophylaxis should be withheld 3, 2
Critical context: Mortality is dramatically higher in patients who develop bleeding (48.5%) versus those who do not (9.1%, p < 0.001), justifying aggressive prophylaxis in high-risk patients 3, 2
Pharmacologic Agent Selection
First-Line Options (Equivalent Efficacy)
- PPIs or H2RAs are equivalent therapeutic options for stress ulcer prophylaxis 1
- Intravenous pantoprazole 40mg daily is preferred in patients with severe liver disease due to consistent acid suppression and reduced hepatic metabolism concerns 1
- H2-receptor antagonists are more efficacious than sucralfate for preventing gastrointestinal bleeding 2
Important Nuance on Agent Selection
The evidence shows conflicting data on PPI versus H2RA superiority. While older guidelines suggested preferring PPIs over H2RAs 1, more recent analysis indicates that when evaluating only trials at low risk for bias, the evidence does not clearly support lower bleeding rates with PPIs over H2RAs 4. However, PPIs appear to be the dominant drug class used worldwide today 4.
Critical Adverse Effect Consideration
Common pitfall: H2-receptor antagonists and antacids increase the risk of ventilator-associated pneumonia (VAP) compared to sucralfate 3
- Ranitidine significantly increases nosocomial pneumonia compared with sucralfate (OR = 1.35,95% CI 1.07–1.70; p = 0.012) 3
- The likelihood of developing VAP is 35% higher in patients using H2-receptor inhibitors and antacids for stress ulcer prophylaxis 3
- Sucralfate is associated with lower mortality (OR = 0.73; 95% CI 0.54–0.97) relative to antacids and H2-receptor antagonists (OR = 0.83; 95% CI 0.63–1.09) 3
- VAP may be more closely related to ICU mortality than stress ulcer bleeding, as both antacids and H2-receptor antagonists raise gastric pH, leading to greater gastric bacterial colonization 3
Despite this mortality signal favoring sucralfate, current guidelines still recommend PPIs or H2RAs as first-line agents 1, 2, likely because the bleeding prevention benefit outweighs pneumonia risk in the highest-risk patients.
Adjunctive Measures
Early Enteral Nutrition
- Early enteral nutrition reduces the risk of stress-related gastric ulcers and should be initiated as soon as possible 1
- Enteral nutrition reduces absolute bleeding risk by 0.3% (95% CI, 0.1-0.7%) 5
- Maintain pharmacologic prophylaxis even in patients receiving enteral nutrition if risk factors persist 5
Duration and Discontinuation
- Maintain prophylaxis as long as risk factors and critical illness persist 1
- Discontinue prophylaxis when sepsis resolves and the patient tolerates enteral nutrition, or when critical illness resolves and risk factors disappear 1