When should stress ulcer prophylaxis be used in the ICU?
OBJECTIVE
To discuss the risk factors and underlying illnesses that play a role in the pathophysiology of stress ulcer, and to evaluate the evidence pertaining to stress ulcer-related bleeding prophylaxis in critically ill patients.


RESULTS
The use of stress ulcer prophylaxis is common in critical care medicine and is a major challenge to physicians in the ICU. The mechanism of stress ulcer is believed to be multifactorial, yet remains incompletely understood. The most widely used drugs for stress ulcer prophylaxis are intravenous histamine2-receptor antagonists. They raise gastric pH, but are associated with the development of tolerance, possible drug interactions, and neurologic manifestations. Sucralfate, which can be administered by the nasogastric route, can protect the gastric mucosa without raising pH, but may decrease absorption of concomitantly administered oral medications. Proton pump inhibitors are the most potent acid-inhibiting pharmacologic agents available. Proton pump inhibitors are at least as effective as histamine2-receptor antagonists, as a limited number of clinical trials have demonstrated. However, these trials were small, lacked an active comparator, varied in the number of risk factors, and used a different definition of clinically important bleeding than previously established.


CONCLUSIONS
Routine prophylaxis against stress ulcers in the ICU is not well justified by current evidence. Patients at risk of stress ulcer-related bleeding are most likely to benefit from prophylaxis. Thus, healthcare professionals should continue to evaluate risk and assess the need for stress ulcer-related prophylaxis.
Quenot
Jean-Pierre
JP
Service de Réanimation Médicale, Dijon University Hospital, Dijon, France. jean-pierre.quenot@chu-dijon.fr
Thiery
Nadiejda
N
Barbar
Saber
S
D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D004750:Enteral Nutrition; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D007362:Intensive Care Units; D010437:Peptic Ulcer / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D054328:Proton Pump Inhibitors; D011968:Receptors, Histamine; D012307:Risk Factors; D013312:Stress, Physiological; D013392:Sucralfate / Q000627:therapeutic use
D000897:Anti-Ulcer Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors; D011968:Receptors, Histamine; D013392:Sucralfate