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 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
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