Indications for PPI Inhibitors in ICU Patients

Coagulopathy is associated with an increased absolute risk of stress-related UGIB of 4.8% (95% CI, 2.6–8.6) 1
Shock is associated with an increased absolute risk of stress-related UGIB of 2.6% (95% CI, 1.2–5.4) 1
Chronic liver disease is associated with an increased absolute risk of stress-related UGIB of 7.6% (95% CI, 3.3–17.6) 1
Mechanical ventilation alone is not considered an independent risk factor for UGIB and does not necessitate stress ulcer prophylaxis (SUP) 1, 3

Role of Enteral Nutrition in Stress Ulcer Prophylaxis

Enteral nutrition (EN) reduces the risk of clinically important stress-related UGIB in critically ill adults 1, 4
Enteral nutrition is associated with a decreased absolute risk of stress-related UGIB of 0.3% (95% CI, 0.1–0.7) 1
However, even patients receiving enteral nutrition should receive SUP if they have one or more risk factors for clinically important stress-related UGIB 1, 3

Either PPIs or histamine-2 receptor antagonists (H2RAs) are recommended as first-line agents for SUP in critically ill adults with risk factors 3, 5
PPIs have been shown to reduce clinically important UGIB (relative risk 0.52; 95% CI, 0.30–0.81) 1
For patients with acute liver failure, H2 blocking agents or PPIs are recommended for prophylaxis of acid-related GI bleeding 7

Either enteral or intravenous routes can be used when administering SUP 8, 5
Low-dose SUP should be administered rather than high-dose SUP 8, 5
"Low-dose" PPI therapy is defined as a daily dose of ≤40mg esomeprazole, omeprazole, or pantoprazole and ≤30mg lansoprazole 8
"Low-dose" H2RA therapy is defined as a daily dose of ≤40mg famotidine, ≤150mg IV ranitidine, ≤300mg enteral ranitidine, and ≤1200mg cimetidine 8

SUP should be discontinued when critical illness is no longer evident or when risk factors are no longer present despite ongoing critical illness 2, 5
Discontinuation of SUP before transfer out of the ICU is necessary to prevent inappropriate prescribing 2, 9

Concurrent administration of SUP with enteral nutrition may increase pneumonia risk 1, 6
The benefits of preventing clinically important UGIB in high-risk patients outweigh the potential risks of SUP 2

In neurocritical care patients, SUP is recommended to reduce clinically important stress-related UGIB 6
These patients may be at additional risk due to physiologic changes resulting in hypersecretion of gastric acid 6