Stress Ulcer Prophylaxis in the Intensive Care Unit (Pharmacology Notes) (Clinical Report)
Stress-related mucosal disease (SRMD) is an acute, erosive gastritis representing conditions ranging from stress-related injury to stress ulcers (1,2). Stress-related injury is superficial mucosal damage that presents primarily as erosions, whereas stress ulcers are deep, focal mucosal damage penetrating the submucosa with high risk for gastrointestinal bleeding (2,3). Mucosal damage has been reported to occur during the first 24 hours of hospital admission in 75% to 100% of intensive care unit (ICU) patients (4,5). Clinically important gastrointestinal bleeding can cause hemodynamic instability and increase the need for red blood cell transfusions (1). Significant bleeding may also increase the length of stay in the ICU and mortality (1). Initiation of acid suppression therapy (AST) for stress ulcer prophylaxis (SUP) in the ICU setting is well established, but the use of SUP in general medicine patients has not been deemed necessary since most experts consider the risk of clinically important bleeding outside of the ICU too low for continuation of SUP (3). The American Society of Health-System Pharmacists (ASHP) published the only available guidelines in 1999 for the use of SUP in medical, surgical, respiratory, and pediatric ICU patients. The guidelines do not recommend SUP in adult patients in non-ICU settings since most clinical trials discontinued prophylaxis without evidence of clinically important bleeding upon extubation or ICU discharge (5). Furthermore, it has been reported that the number needed to treat is 900 patients with low risk for clinically important bleeding to prevent a single episode of clinically significant gastrointestinal bleeding (6). Thus, continuation of SUP in the general medicine setting is not necessary unless patients have at least one independent risk factor increasing the risk of clinically important bleeding (6).