Do all patients in the Intensive Care Unit (ICU) require Stress Ulcer Prophylaxis (SUP)?

Stress Ulcer Prophylaxis in ICU Patients: Risk-Stratified Approach Required

Not all ICU patients require stress ulcer prophylaxis (SUP)—only those with specific risk factors for clinically important gastrointestinal bleeding should receive it. 1

Risk Factors That Mandate SUP

The 2024 Society of Critical Care Medicine guidelines clearly identify three primary risk factors that warrant SUP:

• Coagulopathy (absolute risk increase of 4.8% for stress-related UGIB) 1, 2
• Shock (absolute risk increase of 2.6% for stress-related UGIB) 1, 2
• Chronic liver disease (absolute risk increase of 7.6% for stress-related UGIB) 1, 2

Mechanical ventilation alone does NOT necessitate SUP, contrary to older practice patterns. 1, 2 This represents a significant departure from historical recommendations where prolonged mechanical ventilation (>48 hours) was considered sufficient indication. 3

When NOT to Use SUP

Low-risk ICU patients who are enterally fed and lack the above risk factors should NOT receive SUP. 1 This is a conditional recommendation with very low certainty of evidence, but it addresses the widespread problem of SUP overuse—studies show 68.1% of ICU patients without risk factors inappropriately receive prophylaxis. 4

Role of Enteral Nutrition

Enteral nutrition itself provides protective effects, reducing absolute risk of stress-related UGIB by 0.3%. 2 However, even patients receiving enteral nutrition should receive SUP if they possess one or more of the three major risk factors listed above. 1, 2 This nuance is critical—enteral feeding is not sufficient protection in high-risk patients.

Medication Selection When SUP Is Indicated

When SUP is warranted based on risk factors:

• Use either PPIs or H2RAs as first-line agents (both are acceptable; PPIs show relative risk reduction of 0.52 for clinically important UGIB) 1, 2
• Administer low-dose therapy only: ≤40mg daily of esomeprazole, omeprazole, or pantoprazole 2
• Either enteral or IV routes are acceptable 1, 2

Critical Discontinuation Criteria

SUP must be discontinued when risk factors resolve or before ICU transfer to prevent inappropriate continuation. 1, 2 This is essential because 60.4% of patients continue SUP after ICU transfer despite resolution of risk factors, and 31% are discharged home on agents without valid indication. 4

Important Caveats

Concurrent SUP with enteral nutrition may increase pneumonia risk, though the benefits in high-risk patients outweigh this concern. 1, 2 The older literature suggesting SUP increases ventilator-associated pneumonia has not definitively established impact on mortality and morbidity. 1

SUP has not demonstrated mortality benefit in critically ill patients—its purpose is solely to prevent clinically important bleeding (defined as bleeding causing hemodynamic instability or requiring transfusion). 1, 3

Special Population: Neurocritical Care

Neurocritical care patients warrant SUP due to physiologic changes causing gastric acid hypersecretion, even though this recommendation carries very low certainty of evidence. 1, 2

Algorithm for Decision-Making

1. Assess for major risk factors: coagulopathy, shock, or chronic liver disease
2. If ANY major risk factor present: Initiate low-dose PPI or H2RA regardless of enteral feeding status 1, 2
3. If NO major risk factors present: Do not initiate SUP, even if mechanically ventilated 1, 2
4. Daily reassessment: Discontinue SUP immediately when risk factors resolve 1, 2
5. Before ICU transfer: Review and discontinue SUP if no ongoing indication 1, 2

The evidence strongly supports moving away from universal SUP in all ICU patients toward a risk-stratified approach that balances bleeding prevention against potential harms including infectious complications and unnecessary medication burden. 3, 5