PPI Prophylaxis in Acute Ulcerative Colitis on Steroids and Immunosuppression

Rationale for PPI Use

The British Society of Gastroenterology recommends prophylaxis for patients on ≥20mg prednisolone or equivalent when combined with other immunosuppressants, indicating recognition of the high-risk nature of combination therapy 1
The EULAR gout guidelines state that NSAIDs should be given "plus proton pump inhibitors if appropriate" when used alongside corticosteroids, establishing precedent for gastroprotection with steroid therapy 2
The combination of corticosteroids and immunosuppressants significantly increases gastrointestinal bleeding risk and warrants gastroprotection, as seen in patients on triple immunosuppressive therapy 1

The American Academy of Family Physicians notes that age ≥65 years and concurrent medications affecting coagulation increase baseline bleeding risk, supporting the use of PPI prophylaxis in high-risk patients 4
The American College of Gastroenterology recommends gastroprotection for patients with moderate GI risk factors, which would include combination immunosuppressive therapy 5

Continue PPI throughout the entire steroid course and for at least 2-4 weeks after steroid discontinuation, as recommended by guidelines 3
Monitor patients for signs of GI bleeding, such as melena, hematemesis, unexplained anemia, or hemodynamic instability, and watch for C. difficile infection, which may be increased with PPI use in IBD patients 1, 4
PPIs do not interfere with 5-ASA, corticosteroid, or thiopurine efficacy in UC, and should be continued in patients requiring rescue therapy with infliximab or cyclosporine for steroid-refractory disease 1, 3, 6