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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.
Clinical Pearls:

 To prevent 1 case of clinically important GI bleeding, you need to treat 60 ICU pts1
 To prevent one case of overt GI bleeding, you need to treat 18 ICU pts prophylactically1
 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. Proton pump inhibitors: appropriate use and safety concerns. Pharmacist's Letter/Prescriber's Letter 2010; 26(7):260705. . Descriptive analysis of a clinical pharmacy intervention to improve the appropriate use of stress ulcer prophylaxis in a hospital infectious disease warar;16(2):114-21. Stevens AM, Thomas Z. The case against stress ulcer prophylaxis in 2007. Hospital Pharmac; 42(11):995–1002. Heidelbaugh JJ, Inadomi JM. Magnitude and Economic Impact of Inappropriate Use of Stress Ulcer Prophylaxis in Non-ICU Hospitalized Patients. American Journal of Gastroenterology 2006; doi: 10.1111/j.1572-0241.2006.00839.x Cook DJ, Fuller HD, Guyatt GH, et al. Risk Factors for Gastrointestinal Bleeding in Critically Ill Patients; NEJM 1994; 330(6) :377-81. Farrell CP, Mercogliano G, Kuntz CL. Overuse of stress ulcer prophylaxis in the critical care setting and beyond. J Crit Care 2009; Hussain S, Stefan M, Visintainer P, Rothberg M. Why Do Physicians Prescribe Stress Ulcer Prophylaxis to General Medicine Patients? Southern Medical Journal 2010; 103 (11): 1103-10. Qadeer MA, Richter JE, Brotman DJ. Hospital-Acquired Gastrointestinal Bleeding Outside the Critical Care Unit. Risk Factors, Role of Acid Suppression, and Endoscopy Findings. J Hosp Med 2006; 1 (1):13-20. Sesler JM. Stress-related Mucosal Disease in the Intensive Care Unit. An Update on Prophylaxis. AACN Advanced Critical Care 2007; 18 (2): 119–128. Singh H, Houy TL, Singh N, Sekhon S. Gastrointestinal Prophylaxis in Critically Ill Patients. Crit Care Nurs Q 2008; 31 (4): 291–301. Anon. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health-Syst Pharm. 1999; 56:347-79 Quenot JP, Thiery N, BarbarS. When should stress ulcer prophylaxis be used in the ICU? Current Opinion in Critical Care 2009,15:139–143. Allen ME, Kopp BJ, Erstad BL. Stress ulcer prophylaxis in the postoperative period. Am J Health-Syst Pharm. 2004; 61:588-96 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 infections(Accessed January 31, 2012). Al-Tureihi FI, Hassoun A, Wolf-Klein G, Isenberg H. Albumin, length of stay, and proton pump inhibitors: key factors in Clostridium difficile-associated disease in nursing home patients Cunningham R, Dale B, Undy B, Gaunt N. Proton pump inhibitors as a risk factor for Clostridium difficile diarr 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-associated diseas 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 Shah S, Lewis A, Leopold D, et al. Gastric acid suppression does not promote clostridial diarrhoea in the elderly Dial S, Delaney JA, Schneider V, Suissa S. Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy Dial S, Kezouh A, Dascal A, et al. Patterns of antibiotic use and risk of hospital admission because of Clostridium difficile infecti Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality Akhtar AJ, Shaheen M. Increasing incidence of Clostridium difficile-associated diarrhea in African-American and Hispanic patients: association with the use of proton pump inhibitor therapy Aseeri M, Schroeder T, Kramer J, Zackula R. Gastric acid suppression by proton pump inhibitors as a risk factor for Clostridium difficile-associated diarrhea in hospitalized patients Beaulieu M, Williamson D, Pichette G, Lachaine J. Risk of Clostridium difficile associated disease among patients receiving proton-pump inhibitors in a Quebec medical intensive care uni Cadle R, Mansouri M, Logan N, et al. Association of proton-pump inhibitors with outcomes in Clostridium difficile colitis Dalton B, Lye-Maccannell T, Henderson E, et al. Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low-endemicity, non-outbreak hospital setti Dubberke ER, Reske KA, Yan Y, et al. Clostridium difficile-associated disease in a setting of endemicity: identification of novel risk factors Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infecti Janarthanan S, Ditah I, Kutait A, et al. A meta-analysis of 16 observational studies on proton pump inhibitor use and risk of Clostridium difficile associated diarrhea [abstract]. American College of Gastroenterology Conference 2010; Abstract 378. Jayatilaka S, Shakov R, Eddi R, et al. Clostridium difficile infection in an urban medical center: five-year analysis of infection rates among adult admissions and association with the use of proton pump inhibitors Kazakova SV, Ware K, Baughman B, et al. A hospital outbreak of diarrhea due to an emerging epidemic strain of Clostridium difficile Kim JW, Lee KL, Jeong JB, et al. Proton pump inhibitors as a risk factor for recurrence of Clostridium-difficile-associated diarr Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppressi Linsky A, Gupta K, Lawler EV, et al. Proton pump inhibitors and risk for recurrent Clostridium difficile infecti Lowe DO, Mamdani MM, Kopp A, et al. Proton pump inhibitors and hospitalization for Clostridium difficile-associated disease: a population-based study Turco R, Martinelli M, Miele E, et al. Proton pump inhibitors as a risk factor for paediatric Clostridium difficile infecti Yearsley K, Gilby L, Ramadas A, et al. Proton pump inhibitor therapy is a risk factor for Clostridium difficile-associated diarr


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