Don’t Stress Over New Stress Ulcer Prophylaxis Guidelines

You’ll see new recommendations for stress ulcer prophylaxis (SUP) in the ICU...due to the first guideline update in 25 years.

We know that SUP isn’t needed in all ICU patients. But many previous recommendations came from small, poorly designed studies.

Now data from 3 large, well-designed trials are giving clinicians new guidance on which ICU patients actually need prophylaxis.

Know what’s changed...and be ready to implement new recommendations.

For example, we used to give SUP to almost all mechanically ventilated patients. But there’s no conclusive evidence that mechanical ventilation alone is an indication to start prophylaxis.

Instead, new guidelines recommend reserving SUP for critically ill patients with coagulopathies (INR above 1.5, etc), shock, or chronic liver disease. Also consider SUP for neurocritical care patients with risks.

And continue to use SUP in patients receiving enteral nutrition with one or more of these risk factors. But avoid use in low-risk patients, since this combo may increase pneumonia risk.

Continue to recommend a PPI or H2-blocker for SUP...neither has a clear advantage. Use the lowest dose for the shortest duration...and transition to enteral route when able, since there’s no proof IV is best.

Be aware, some studies that compare PPIs to H2-blockers or placebo in critically ill patients suggest that PPIs are associated with lower GI bleeding risk...but not a mortality benefit.

Clarify that newer data suggest that PPIs alone do NOT increase risk of C. diff or pneumonia...and short-term side effects are typically mild.

Monitor the need for prophylactic meds daily...and stop when risks resolve. Don’t let prophylaxis continue during transitions of care...such as transfer to the floor or at discharge.

Double-check that orders for PPIs and H2-blockers are coming from the correct order sets, especially for non-ICU patients...they rarely require stress ulcer prophylaxis.

Clarify whether preadmission PPIs or H2-blockers are actually needed long term...and discontinue treatment if they’re unnecessary.

But if patients do need to stay on these acid reducers, verify that all formulary interchanges are switched back to the patient’s home med...so they don’t get discharged on duplicate therapy.