Routine PPI use ('stress ulcer prophylaxis') is standard practice in some ICUs, however it has been found that as many as 40% of these patients continue taking the medication on hospital discharge, with the attendant risks of Clostridium difficile infection, community-acquired pneumonia and osteoporosis.
Our ICU is currently developing guidelines on postoperative care for cardiac surgical patients, primarily to provide a basic framework for junior doctors regarding routine practice in the absence of any specific indications/contraindications.
I am interested in hearing how people interpret the risk/benefit profile of giving, for example, 40mg IV pantoprazole daily, to post-cardiac surgical patients as routine practice. Should it be used universally, liberally, sparingly, or not at all for this purpose?
As long as the patient is intubated - mechanically ventilated and likely insufficiently sedated, one may consider that the patient is under sufficient stress, which would justify to provide stress ulcer prophylaxis. However, if the patient is awake-alert, not stressed, and being fed, then stress ulcer prophylaxis can be discontinued.
Please also note that H-2 blockers are also good agents for stress ulcer prophylaxis and bringing considerably less chances of pneumonia and C. diff infections to our patients.
Please check out the landmark article by Cook et Al in NEJM. It looked at the risk of developing stress ulcer in critically ill patient. In multivariate only two conditions increased the risk of stress ulcers mechanical ventilation greater than 48 hours and coaguloapthy.
The American Society of Health System Pharmacist publish the most widely accepted guidelines for stress ulcer prophylaxis. New guidelines are expected soon.
Finally, please see the article H2RA vs PPI in JAMA 2014 By MacLaren and colleagues that found higher incidence of hemorrhage, pneumonia and CDI with PPI over H2RA.
As a side note considering administration- PPI cannot be crushed and given via an NG tube. Special formulations must be used or IV. H2RA, however, can be crused. Using the oral formulation via NG tube can offer a significant cost savings. For example, oral famotidine is ~1/50th the cost of IV pantoprazole.
Another problem with PPI's is the interaction with clopidogrel. This interaction does not exist with H2-antagonists
Thank you for your responses. I find the comparisons between PPIs and H2RAs interesting - do some institutions routinely use these instead?
Many family doctors are not aware about the attendant risks (Clostridium difficile infection, community-acquired pneumonia and osteoporosis) associated with prolonged PPI therapy.
We use H2RAs routinely for prophylaxis, primarily to prevent stress ulcers post cardiac surgery till the time patient is ambulatory and accepting feeds normally and reason definitely is the cost difference. However we do switch over to intravenous infusions of PPIs at first evidence of stress ulcers.
I would not endorse it as a routine practice and if needed would prefer through NG tube for a short span.
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