PRESCRIBING PRACTICES RELATED TO DISCONTINUATION OF STRESS ULCER PROPHYLAXIS IN PATIENTS WITH RISK FACTORS FOR CLINICALLY SIGNIFICANT GASTROINTESTINAL BLEEDING

ABSTRACT Background: The physiological stress of critically ill patients can trigger several complications, including digestive bleeding due to stress ulcers (DBSU). The use of acid secretion suppressants to reduce their incidence has become widely used, but with the current understanding of the risks of these drugs, their use, as prophylaxis in critically ill patients, is limited to the patients with established risk factors. Aim: To determine the appropriateness of the use of prophylaxis for stress ulcer bleeding in acutely ill patients admitted to intensive care units and to analyze the association of risk factors with adherence to the prophylaxis guideline. Methods: Retrospective, analytical study carried out in three general adult intensive care units. Electronic medical records were analyzed for epidemiological data, risk factors for DBSU, use of stress ulcer prophylaxis, occurrence of any digestive bleeding and confirmed DBSU. The daily analysis of risk factors and prophylaxis use were in accordance with criteria based on the Guidelines of the Portuguese Society of Intensive Care for stress ulcer prophylaxis. Results: One hundred and five patients were included. Of the patient days with the opportunity to prescribe prophylaxis, compliance was observed in 95.1%. Of the prescription days, 82.35% were considered to be of appropriate use. Overt digestive bleeding occurred in 3.81% of those included. The occurrence of confirmed DBSU was identified at 0.95%. Multivariate analysis by logistic regression did not identify risk factors independently associated with adherence to the guideline, but identified risk factors with a negative association, which were spinal cord injury (OR 0.02 p <0.01) and shock (OR 0.36 p=0.024). Conclusion: The present study showed a high rate of adherence to stress ulcer prophylaxis, but with inappropriate use still significant. In the indication of prophylaxis, attention should be paid to patients with spinal cord injury and in shock.

Download Full-text

Stress ulcer prophylaxis and treatment drugs in critical illness

10.1093/med/9780199600830.003.0041 ◽

2016 ◽

Author(s):

Waleed Alhazzani ◽

Deborah J. Cook

Keyword(s):

Length Of Stay ◽

Gastrointestinal Bleeding ◽

Stress Ulcer ◽

Randomized Clinical Trials ◽

Epidemiological Data ◽

Stress Ulcer Prophylaxis ◽

Patient Specific ◽

Icu Mortality ◽

Moderate Quality ◽

Ulcer Prophylaxis

Many changes have occurred over the last three decades in the field of stress ulcer gastrointestinal bleeding and its prevention. The topic is controversial, fuelled by disparate data, studies at risk of bias, and the impression that the problem is not as serious as it once was. Indeed, compared with over four decades ago when mucosal ulceration of the stomach causing serious bleeding was first described, a relatively small proportion of critically-ill patients now develop clinically important bleeding. Acid suppression is commonly prescribed for stress ulcer prophylaxis (SUP), targeting subgroups of patients at high risk in the intensive care unit (ICU), rather than universal prevention. The randomized clinical trials to date suggest a significant reduction in CIB with use of histamine-2-receptor antagonists (H2RAs) compared with no SUP, with no impact on pneumonia, ICU mortality, or length of stay. However, these trials are of moderate quality. More recent RCTs suggest proton pump inhibitors compared with H2RAs may significantly reduce the risk of CIB without influencing the risk of pneumonia, ICU mortality, or length of stay. These trials are also of moderate quality. Today, the decision whether to use SUP, and which agent to use, is complex. Clinical considerations include local epidemiological data (for centres documenting these outcomes), and patient-specific risks of gastrointestinal bleeding and infection, indexed to case mix.

Download Full-text

Stress ulcer prophylaxis plus enteral nutrition versus enteral nutrition alone in critically ill patients at risk for gastrointestinal bleeding: a propensity-matched analysis

Intensive Care Medicine ◽

10.1007/s00134-020-06136-w ◽

2020 ◽

Vol 46 (10) ◽

pp. 1948-1949

Author(s):

Hiroyuki Ohbe ◽

Kojiro Morita ◽

Hiroki Matsui ◽

Kiyohide Fushimi ◽

Hideo Yasunaga

Keyword(s):

At Risk ◽

Enteral Nutrition ◽

Gastrointestinal Bleeding ◽

Critically Ill ◽

Critically Ill Patients ◽

Stress Ulcer ◽

Stress Ulcer Prophylaxis ◽

Patients At Risk ◽

Ulcer Prophylaxis

Download Full-text

Evaluation of Stress Ulcer Prophylaxis Guideline in the Intensive Care Units of a Teaching Hospital: A Cross Sectional Study

Journal of Pharmaceutical Care ◽

10.18502/jpc.v8i2.3830 ◽

2020 ◽

Author(s):

Afsaneh Vazin ◽

Seyed Ruhollah Mousavinasab ◽

Golnar Sabetian

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Intensive Care ◽

Intensive Care Units ◽

Stress Ulcer ◽

Mucosal Damage ◽

Stress Ulcer Prophylaxis ◽

Major Risk Factor ◽

Cross Sectional ◽

Ulcer Prophylaxis

Background: One of the complications of critical ill patients admitted to intensive care unit (ICU) are stress-related mucosal damage. Stress ulcer prophylaxis (SUP) should be administered to all critically ill patients with at least one major risk factor and two or more minor criteria. Methods: This study was performed during 6 months from October 2013 to December 2013 in Namazi Hospital intensive care units to assess the appropriate administration of SUP, according to American Society of Health-System Pharmacists (ASHP) protocol. Candidate for SUP according the ASHP guideline is considered if there is a at least one major risk factor or two or more minor risk factors. Results: Ninety-four patients were enrolled (46 men and 48 women). The mean age of study subjects was 51.5 years. The most major risk factor to stress ulcer found to be mechanical ventilation more than 48 hours (53%). The most minor risk factor for stress ulcer was ICU admission for less than one week (23.5%). Most prescribed medication for stress ulcer prophylaxis was intravenous Pantoprazole (44.7%). Our results have shown that about 74% patients were candidate for SUP according the ASHP guideline. 13(13.8%) of patients had only major risk factors. 5 (5.3%) of patients received SUP while they did not have at least one major risk factor or two or more minor risk factors. Conclusion: Our results have shown that 76.2% of the total SUP administrations were compliant with the ASHP guideline. Among the prescribed medication for SUP, intravenous pantoprazole had the highest percentage of administration (44.7%) and oral omeprazole had the lowest percentage of administration (7.4%). According to the results of our study, 72% of the route administrations are compliant with the ASHP guideline.

Download Full-text

Comparison of proton pump inhibitors and histamine 2 receptor antagonists for stress ulcer prophylaxis in the intensive care unit

Scientific Reports ◽

10.1038/s41598-021-98069-7 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Myung Jin Song ◽

Seok Kim ◽

Dachung Boo ◽

Changhyun Park ◽

Sooyoung Yoo ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Adverse Events ◽

Gastrointestinal Bleeding ◽

Critically Ill ◽

Proton Pump ◽

Critically Ill Patients ◽

Stress Ulcer ◽

Stress Ulcer Prophylaxis ◽

Ulcer Prophylaxis

AbstractProton pump inhibitors (PPIs), followed by histamine 2 receptor antagonists (H2RAs), are the most commonly used drugs to prevent gastrointestinal bleeding in critically ill patients through stress ulcer prophylaxis. The relative efficacy and drug-related adverse events of PPIs and H2RAs remain unclear. In this retrospective, observational, comparative cohort study, PPIs and H2RAs for stress ulcer prophylaxis in critically ill patients were compared using a common data model. After propensity matching, 935 patients from each treatment group (PPI or H2RA) were selected. The PPI group had a significantly higher 90-day mortality than the H2RA group (relative risk: 1.28; P = 0.01). However, no significant inter-group differences in the risk of clinically important gastrointestinal bleeding were observed. Moreover, there were no significant differences between the groups concerning the risk of pneumonia or Clostridioides difficile infection, which are known potential adverse events related to these drugs. Subgroup analysis of patients with high disease severity were consistent with those of the total propensity score-matched population. These findings do not support the current recommendations, which prefer PPIs for gastrointestinal bleeding prophylaxis in the intensive care unit.

Download Full-text