Stress Ulcer Prophylaxis: Do No Harm

Abstract & Commentary

By Saadia R. Akhtar, MD, MSc, Idaho Pulmonary Associates, Boise. Dr. Akhtar reports no financial relationship to this field of study. This article originally appeared in the December 2009 issue of Critical Care Alert. It was edited by David J. Pierson, MD and peer reviewed by William Thompson, MD. Dr. Pierson is Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, and Dr. Thompson is Staff Pulmonologist, VA Medical Center; Associate Professor of Medicine, University of Washington; they report no financial relationships relevant to this field of study.

Synopsis: A single-center, retrospective, observational study found that stress ulcer prophylaxis is used in a majority of ICU patients, despite absence of risk factors for stress ulcers.

Source: Farrell CP, et al. Overuse of stress ulcer prophylaxis in the critical care setting and beyond. J Crit Care. 2009 Aug 14; Epub ahead of print.

This study's primary aim was to document the risk factors for stress ulcers and the use of stress ulcer prophylaxis (SUP) in patients upon ICU admission, transfer to the floor, and discharge home. Retrospective chart review was performed for all patients admitted over a four-month period to the mixed medical-surgical ICU of an academic institution. Exclusion criteria were: age < 16 years, admission diagnosis of gastrointestinal (GI) bleeding, new onset gastroesophageal reflux disease or esophagitis, allergy to H2 antagonists, and withdrawal of care at admission. Data collected included usual demographics, admission diagnoses, and preadmission medications. Risk factors for stress ulcers were categorized as major (mechanical ventilation or coagulopathy) or minor (sepsis, severe hypotension, acute renal or hepatic failure, severe head or spinal cord trauma, history of GI bleeding, severe burn injury, prolonged major surgery, or high-dose corticosteroids). Patients were classified into four groups: presence of a major risk factor, only minor risk factors, no risk factors, or home use of acid-suppressive medications.

The study included 210 patients; 31 others were excluded per the predefined study criteria. Upon admission to the ICU, 87% of patients received SUP. This figure was > 95% for patients with a major risk factor and > 82% for patients with only a minor risk factor. Of the patients with no risk factors for stress ulcers, 68% received SUP. One hundred ninety patients survived to transfer out of the ICU to the ward; of those with no risk factors for stress ulcers, 60% remained on prophylaxis. One hundred eighty-five patients survived to hospital discharge; of those with no risk factors for stress ulcers, 31% were discharged home on prophylaxis. The authors performed some secondary analyses in an attempt to identify potential factors (age, sex, and the previously defined major and minor risk factors for stress ulcers) more likely to be associated with use of SUP; as expected, an association was seen with ventilator-dependent respiratory failure, but little other information could be garnered.

Commentary

Use of SUP in the ICU has been part of routine practice for about two decades. Progression of untreated stress ulcers to clinically important GI bleeding clearly worsens ICU morbidity and mortality.1 The strongest indications for SUP are mechanical ventilation > 48 hours and coagulopathy (platelet count < 50,000/m3, International Normalized Ratio > 1.5, or partial thromboplastin time > 2 times the upper limit of normal), as reported in Cook et al's large prospective multicenter observational study.2 A variety of smaller (much less robust) studies suggest increased stress ulcer risk in other ICU populations, including patients with sepsis, hypotension, head or spinal cord trauma, multiple trauma, severe burns, and acute renal or hepatic failure; despite limited data, the recommendation to treat such patients with SUP is included in some expert guidelines.3 Furthermore, some experts advocate SUP for ICU patients receiving high-dose glucocorticoids (particularly in combination with other risk factors such as aspirin), those with a prior recent history of peptic ulcer disease or GI bleeding, and prolonged ICU stay (one week or longer). Finally, there is essentially no evidence to support use of stress ulcer prophylaxis in non-ICU hospital patients.4

In comparing medications available for SUP, H2 blockers have been shown to be more effective than sucralfate, and both appear superior to antacids alone; it remains unclear whether proton pump inhibitors are superior or simply equivalent to H2 blockers. Enteral nutrition may reduce the risk of stress ulceration with clinically important GI bleeding; however, it is unknown whether enteral nutrition alone gives protection equivalent to that offered by acid-suppressive agents.5

Farrell et al's report reiterates what has been described previously by other authors. Intensivists are appropriately treating the majority of at-risk patients with SUP; we are also unnecessarily treating a large number (more than two-thirds in this study) of other patients. This excess administration of stress gastritis prophylaxis in the ICU and non-ICU settings is not benign. Patients are placed at risk of common side effects of SUP medications (for example, altered mental status with H2 antagonists, or diarrhea and other GI upset with proton pump inhibitors), as well as medication interactions and frank allergic reactions. There is evidence to suggest that increased nosocomial pneumonia may be seen with use of certain medications for SUP.6 In addition, inappropriate medication prescription poses significant economic burdens to hospitals and individuals.4

It behooves all of us to do no harm; Farrell et al have reminded us that we must examine our practices and use SUP only for those ICU patients expected to reap benefit.

References

1. Cook DJ, et al. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care 2001;5:368-375.

2. Cook DJ, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994;330:377-381.

3. Dellinger RP, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296-327.

4. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm 2007;64:1396-1400.

5. Cook D, et al. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. Crit Care Med 1999;27:2812-2817.

6. Kallet RH, Quinn TE. The gastrointestinal tract and ventilator-associated pneumonia. Respir Care 2005; 50:910-921.