From the Guidelines
GI prophylaxis in the ICU is recommended for critically ill patients at high risk for stress ulcers, with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) as the preferred agents, as stated in the 2024 guideline by the Society of Critical Care Medicine and American Society of Health-System Pharmacists 1. The use of PPIs or H2RAs for stress ulcer prophylaxis (SUP) is supported by the most recent evidence, which suggests that these agents can reduce the occurrence of clinically important stress-related upper gastrointestinal bleeding (UGIB) in critically ill adults with risk factors for developing stress-related UGIB 1. Some key points to consider when implementing GI prophylaxis in the ICU include:
- Initiating prophylaxis promptly upon ICU admission for patients with risk factors, such as mechanical ventilation for >48 hours, coagulopathy, history of GI bleeding, traumatic brain injury, burns >35% BSA, multiple trauma, or hepatic or renal failure.
- Using either PPIs, such as pantoprazole 40 mg IV or PO daily, or H2RAs, like famotidine 20 mg IV or PO twice daily, as first-line therapy.
- Reassessing therapy daily and discontinuing when risk factors resolve or upon ICU discharge, unless there are ongoing indications.
- Considering the potential benefits and risks of PPIs and H2RAs, including the slightly higher rates of hospital-acquired pneumonia and C. difficile infection associated with PPIs. The mechanism of protection provided by PPIs and H2RAs works by raising gastric pH above 4, which prevents stress-related mucosal damage that occurs due to splanchnic hypoperfusion and reduced mucosal defense mechanisms in critically ill patients, as noted in the 2017 Surviving Sepsis Campaign guidelines 1.
From the Research
GI Prophylaxis in ICU
- The use of gastrointestinal bleeding prophylaxis in critically ill patients is a common practice to prevent upper gastrointestinal bleeding [ 2 ].
- A clinical practice guideline recommends the use of proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) for gastrointestinal bleeding prophylaxis in critically ill patients at high risk of clinically important gastrointestinal bleeding [ 2 ].
- However, the choice between PPIs and H2RAs remains unclear, with some studies suggesting that PPIs may increase the risk of pneumonia [ 2 ] and mortality [ 3, 4 ].
Comparison of PPIs and H2RAs
- A retrospective, observational, comparative cohort study found that PPIs were associated with a higher 90-day mortality than H2RAs [ 3 ].
- A systematic review and meta-analysis found that PPIs were more effective than H2RAs in preventing upper gastrointestinal bleeding, but the certainty of evidence was low [ 5 ].
- Another study found that the use of PPIs for stress ulcer prophylaxis in critically ill patients may increase mortality compared to H2RAs [ 4 ].