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Stress ulcer prophylaxis
GUIDELINES FOR APPROPRIATE STRESS ULCER PROPHYLAXIS
The following information, derived from the ASHP guidelines, can be used as a screening
tool to determine appropriateness of prophylaxis.
Medical Intensive Care Unit patients
ONE OR MORE OF THE FOLLOWING RISK FACTORS
• Likely to require mechanical ventilation for > 48 hours
• Non-intentional coagulapathy, i.e. not on warfarin, heparin, or other anticoagulants resulting
in an INR > 1.5, platelets < 50,000 or therapeutic aPTT
Medical Intensive Care Unit patients
TWO OR MORE OF THE FOLLOWING RISK FACTORS
• History of gastric ulceration or bleeding within the last 12 months PTA
• Head injury with Glascow Coma Score (GCS) < 10
• Multiple trauma with an injury severity score > 16
• Hepatic failure or renal failure (serum creatinine > 5.7 mg/dL)
Stress Ulcer Prophylaxis
Stress ulcers are superficial inflammatory lesions of the gastric mucosa caused by abnormally
elevated physiological demands on the body. Studies have reported evidence of mucosal damage within 24 hours of admittance in 75-100% of intensive care unit (ICU) patients. This damage can be associated with a significant bleeding risk and therefore, certain patients require prophylaxis. The most current guidelines for stress ulcer prophylaxis (SUP), written by the American Society of Health-System Pharmacists (ASHP) in 1999, include recommendations for ICU patients only. Prophylaxis is not recommended for medical or surgical patients who are not in the ICU. However, data has shown that inappropriate use of acid-suppressive therapy (AST) in general medicine units has been as high as 71%. The use of AST has been linked to an increased risk of serious infections such as pneumonia and Clostridium difficile
associated disease along with elevated risk of fractures. Inappropriate use also increases drug costs for hospitals and patients. For these reasons, it is important to determine the patient populations in which stress ulcer prophylaxis is appropriate.
To prevent 1 case of clinically important GI bleeding, you need to treat 60 ICU pts
To prevent one case of overt GI bleeding, you need to treat 18 ICU pts
One add’l case of nosocomial pneumonia will occur for every 25 ICU pts
treated with H2RA1
Outpatient treatment with PPI has a 2.9-fold higher incidence
of community-acquired C. difficile
H2RAs have a 2-fold higher incidence2 risk associated with inpatient C. difficile.
Corticosteroid use alone is not a risk factor for stress ulcers1,2,3
Coagulopathies must be intrinsic-not resulting from treatment with warfarin or heparin, etc.3
Most data uses H2RA, antacids, or sucralfate in studies, very little data on use of PPIs
Most patients will not
meet criteria for stress ulcer prophylaxis
Trials only in ICU patients; there is NO DATA IN MEDICAL PATIENTS
Stress ulcer prophylaxis in hospitalized patients not in intensive care unitsul 1;64(13):1396-400.
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Proton Pump Inhibitors (PPIs) - Drug Safety Communication: Clostridum Difficile-Associated Diarrhea (CDAD) Can be Associated With Stomach Acid Drugs
U.S. National Library of Medicine. National Institutes of Health. Health topics-Clostridium difficile
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-associated disease in nursing home patients
Cunningham R, Dale B, Undy B, Gaunt N. Proton pump inhibitors as a risk factor for Clostridium difficile
Dial S, Alrasadi K, Manoukian C, et al. Risk of Clostridium difficile
diarrhea among hospital in-patients prescribed proton pump inhibitors:cohort and case-control studies
Dial S, Delaney JA, Barkun A, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile
Muto C, Pokrywka M, Shutt K, et al. A large outbreak of Clostridium difficile-
associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone us
Pepin J, Saheb N, Coulombe MA, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile
-associated diarrhea: a cohort study during an epidemic in Quebec
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Dial S, Delaney JA, Schneider V, Suissa S. Proton pump inhibitor use and risk of community-acquired Clostridium difficile
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Akhtar AJ, Shaheen M. Increasing incidence of Clostridium difficile
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EFDAEuropean Fusion Development Agreement Issue 2000/1 I N FORM AT I ON F U SI ON Fusion energy from the sun Fusion Energy: has warmed the earth for billions of years. Today, sci- An Option for the Future entists and engineers have achieved the first demonstra- tions of a process for releas- ing fusion energy similar that which takes place in the sun. This
The Politics of Identity and Australian Muslim Students’ Associations: A Preliminary Survey of the Literature. 1 Introduction The distinction between Islam and the ‘various manifestations of its practice [is] a subtle but extremely important one,’2 when gauging the impact of religiosity on the identities of Muslim youths in diaspora. One might expect that in an age of accelerate