185 - They Are Late, but Don’t Stress: The New 2024 Stress Ulcer Prophylaxis Guidelines

HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast

Sean P. Kane, PharmD, BCPS

Health & Fitness, Medications, Rosalindfranklin, Rfums, Pharmacy, Pharmd, Pharmacist, Medicine, Drugs

5 • 644 Ratings

🗓️ 4 October 2024

⏱️ 34 minutes

🔗️ Recording | iTunes | RSS

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Summary

In this episode, we review the recommendations from the 2024 SCCM/ASHP stress ulcer prophylaxis guidelines and highlight three of the more recent landmark critical care trials investigating the role of stress ulcer prophylaxis.

Key Concepts

After 25 years, the stress ulcer prophylaxis guidelines have been updated by SCCM and ASHP. These guidelines make 13 recommendations in a PICO format.
Three large, landmark randomized controlled trials (SUP-ICU, PEPTIC, and REVISE) have significantly contributed to the body of literature regarding stress ulcer prophylaxis.
The SCCM/ASHP guidelines recommend stress ulcer prophylaxis in patients with coagulopathy, shock, chronic liver disease, and possibly in neurocritical care patients. They do not specifically recommend prophylaxis in mechanically ventilated patients; this is a controversial recommendation.
The SCCM/ASHP guidelines equally prefer proton pump inhibitor (PPI) and histamine-2 receptor antagonists (H2RA) drug therapies given either intravenously or orally. The prophylaxis regimen should be continued until the indication for prophylaxis has resolved or the patient leaves the ICU.

References

MacLaren R, Dionne JC, Granholm A, et al. Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med. 2024;52(8):e421-e430. doi:10.1097/CCM.0000000000006330
SUP-ICU study. Krag M, Marker S, Perner A, et al. Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU. N Engl J Med. 2018;379(23):2199-2208. doi:10.1056/NEJMoa1714919
PEPTIC study. PEPTIC Investigators for the Australian and New Zealand Intensive Care Society Clinical Trials Group, Alberta Health Services Critical Care Strategic Clinical Network, and the Irish Critical Care Trials Group, Young PJ, Bagshaw SM, et al. Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation: The PEPTIC Randomized Clinical Trial. JAMA. 2020;323(7):616-626. doi:10.1001/jama.2019.22190
REVISE study. Cook D, Deane A, Lauzier F, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024;391(1):9-20. doi:10.1056/NEJMoa2404245

Transcript

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0:00.0	Welcome to Helix Talk, an educational podcast for healthcare students and providers covering real-life clinical pearls, professional pharmacy topics, and drug therapy discussions.
0:11.0	This podcast is provided by pharmacists and faculty members at Rosal Franklin University College of Pharmacy.
0:17.0	This podcast contains general information for educational purposes only. This is not professional
0:22.4	advice and should not be used in lieu of obtaining advice from a qualified health care provider.
0:27.2	And now, on to the show. Welcome to Helix Talk episode 185. I'm your co-host, Dr. Kane.
0:35.6	And I'm Dr. Patel. And the title of today's episode is
0:38.7	They Are Late, But Don't Stress, the new 2024 Stress Ulcer Prophylaxis Guidelines. So it seems
0:45.3	like Dr. Kane, it's been a long time since these guidelines have been updated. So I think
0:51.3	we're going to summarize the recommendation from the SCCM ASHP guidelines, which were recently published, and also discussed the landmark trials that kind of shaped up the recommendations for the guidelines.
1:03.0	Yeah, kind of plot twist me personally as a critical care pharmacist, I'm disagreeing a little bit with the guidelines.
1:08.0	So we'll get to that later on. But I think it's healthy to have
1:11.7	some degree of disagreement or maybe not full alignment with guidelines. And that's why we look at
1:16.9	the primary literature. And this is actually not common. We see European guidelines conflicting with
1:22.2	U.S. guidelines all the time. We're two different U.S. guidelines not being in alignment. So we'll
1:26.4	definitely get to that today.
1:33.2	Right. I think before we get there, though, let's kind of set the foundation for our audience to talk about what is stress ulcer and what is the prophylaxis that we do for stress ulcers.
1:39.0	Yeah, so kind of as the name suggests, when critically ill patients get quote unquote stressed,
1:43.8	they have breakdown of their
1:45.2	gastric mucosa and they're prone to ulcerations and their gastric lining. They can either perforate
1:51.5	where then the stomach acid can leak out into their abdomen or if it's right next to a blood vessel,
1:56.7	that ulcer can actually cause a GI bleed, which is the main manifestation of a stress ulcer
2:01.9	for a critically ill patient. And I believe this happens because there is not enough perfusion
	...

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