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stress ulcer prophylaxis

Management: - no benefit (or harm) of pantoprazole for stress ulcer prophylaxis [1] - even high-risk patients may not benefit [2] - high-risk patient in ICU may not benefit [3]* - no effect on hospital stay, ICU stay, mechanical ventilation or mortality but may prevent clinically significant upper GI bleeding [4,5,6] - reserve proton pump inhibitor prophylaxis for - critically ill patients with coagulopathy - patients with a history of upper GI bleeding - mechanical ventilation for > 48 hours [7] - >= 2 risk factors (sepsis, high-dose glucocorticoid) - proton-pump inhibitors prevent upper GI bleeding in critically ill patients & may limit mortality in less severely ill patients. [8] * significant upper GI bleeding is relatively rare in critically ill patients [3]

Related

stress ulceration

General

GI prophylaxis

References

  1. Selvanderan SP1, Summers MJ, Finnis ME et al Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study. Crit Care Med. 2016 Oct;44(10):1842-50 PMID: 27635481 - Marik PE Stress Ulcer Prophylaxis Deadoption: What is the Barrier? PMID: 27635486
  2. Cook D, Guyatt G. Prophylaxis against Upper Gastrointestinal Bleeding in Hospitalized Patients. N Engl J Med 2018; 378:2506-2516. June 28, 2018 PMID: 29949497 https://www.nejm.org/doi/full/10.1056/NEJMra1605507
  3. Krag M, Marker S, Perner A et al. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med 2018 Oct 24; PMID: 30354950 Free Article - Barkun A, Bardou M. Proton-pump inhibitor prophylaxis in the ICU - Benefits worth the risks? N Engl J Med 2018 Oct 24; PMID: 30354949 Free Article
  4. Young PJ et al. Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital mortality among ICU patients receiving invasive mechanical ventilation: The PEPTIC randomized clinical trial. JAMA 2020 Jan 17; PMID: 31950977 https://jamanetwork.com/journals/jama/article-abstract/2759412
  5. Wang Y et al. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: Systematic review and network meta-analysis. BMJ 2020 Jan 6; 368:l6744 PMID: 31907166 https://www.bmj.com/content/368/bmj.l6744
  6. Medical Knowledge Self Assessment Program (MKSAP) 19 American College of Physicians, Philadelphia 2022
  7. NEJM Knowledge+ Gastroenterology
  8. Cook D, Deane A, Lauzier F et al. Stress ulcer prophylaxis during invasive mechanical ventilation. N Engl J Med 2024 Jun 14; [e-pub] PMID: 38875111 https://www.nejm.org/doi/10.1056/NEJMoa2404245 - Wang Y, Parpia S, Ge L et al. Proton-pump inhibitors to prevent gastrointestinal bleeding - An updated meta-analysis. NEJM Evid. 2024 Jul;3(7):EVIDoa2400134 PMID: 38874580 https://evidence.nejm.org/doi/10.1056/EVIDoa2400134 - Brown SM. Uncertain answers - Proton-pump inhibition in the ICU. N Engl J Med 2024 Jun 14; PMID: 38875100 https://www.nejm.org/doi/10.1056/NEJMe2405782