In this episode, I’ll discuss stress ulcer prophylaxis recommendations from the AHA’s recent statement on Prevention of Complications in the Cardiac Intensive Care Unit.
Stress ulcer prophylaxis guidelines are over 20 years old, and there is no sign anymore of an update of the 1999 ASHP guidelines on the horizon.
There is still considerable debate about who needs prophylaxis, and whether an H2RA or PPI should be used. The original studies that described the incidence of stress ulcers are considered at risk of bias and may not be applicable any longer to modern practice.
Trials and meta-analyses conflict or even suggest no difference between treatment and placebo.
A newly published statement by AHA on Prevention of Complications in the Cardiac Intensive Care Unit contains a section on stress ulcer prophylaxis recommendations.
The AHA highlights the status of the current evidence:
Newer evidence suggests that stress ulcer prophylaxis may be associated with reduced gastrointestinal bleeding in high-risk patients but overall has no demonstrated mortality benefit, and the number needed to treat is high.
Routine use of stress ulcer prophylaxis is not necessary for low-risk patients in the CICU.
Stress ulcer prophylaxis is reasonable for patients in the CICU with multiple risk factors for gastrointestinal bleeding…although the data supporting this approach are weak.
Concerns have been raised that stress ulcer prophylaxis may increase the risk of infectious complications such as CDI or pneumonia, although this remains controversial.
Further uncertainty exists in regard to the optimal agent for prophylaxis. In general, proton pump inhibitors (PPIs) have greater efficacy for preventing gastrointestinal bleeding. Although histamine-2 receptor antagonists have a lower risk of infectious complications, they are associated with a higher risk of thrombocytopenia and may be less optimal in the CICU.
The authors of this AHA statement do not go so far as to provide recommendations, but they state the use of PPIs for stress ulcer prophylaxis in CICU patients is reasonable under the following scenarios:
- Patients with multiple risk factors for gastrointestinal bleeding (including patients with shock, acute kidney injury requiring renal replacement therapy, MV, liver disease, use of anticoagulants, and ongoing coagulopathy as defined by platelet count <50000/m3 , an international normalized ratio >1.5, or a partial thromboplastin time >2 times the control value or on dual antiplatelet therapy)
- Patients on ECMO or mechanical circulatory support
- Patients requiring dual or triple antithrombotic therapy
Other than further review articles and meta-analyses, this statement by the AHA is likely the closest we’ll get to stress ulcer prophylaxis guidelines for the foreseeable future.
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