Rational use of acute gastric mucosal injury prophylaxis in intensive care unit without compromising patient safety: a cohort study
DOI:
https://doi.org/10.30968/jhphs.2025.162.1290Abstract
Background Acute gastric mucosal injury poses a significant risk of gastrointestinal bleeding in intensive care unit patients. Prophylaxis is frequently applied but its indiscriminate use may cause adverse effects. Objective: To evaluate the effectiveness and safety of a rational prophylaxis protocol for acute gastric mucosal lesions in critically ill patients based on clinical risk criteria. Methods: Retrospective observational study with a comparative analysis between two periods: cohort 1 (January to December 2021), before the protocol implementation, and cohort 2 (January to December 2022), after adopting the protocol based on the criteria proposed by Ye et al. (2020). The outcomes analyzed were the use of proton pump inhibitors (PPIs), upper gastrointestinal bleeding (UGIB), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection. Results: A total of 1,614 patients were included, 641 in the pre-exposure group and 973 in the post-exposure group. There was no difference in age, sex, disease severity, previous comorbidities, or use of intensive therapies between groups. The results indicated a significant reduction in proton pump inhibitors use, from 51% in the pre-exposure group to 40% in the post-exposure group (P < 0.001). Furthermore, no significant differences were observed between groups for diagnostic outcomes of gastrointestinal bleeding, respiratory complications, healthcare-associated infections, duration of mechanical ventilation, length of hospital stay, or mortality. Conclusion: The protocol for the rational use of proton pump inhibitors was effective in reducing the use of these drugs without compromising the safety and clinical outcomes of intensive care unit patients. These results must be confirmed by randomized control trials.
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Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113. doi:10.7326/0003-4819-152-2-201001190-00009
Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994;330(6):377-381. doi:10.1056/NEJM199402103300601
Cook DJ, Griffith LE, Walter SD, et al. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care. 2001;5(6):368-375. doi:10.1186/cc1071
Barletta JF, Bruno JJ, Buckley MS, Cook DJ. Stress Ulcer Prophylaxis. Crit Care Med. 2016;44(7):1395-1405. doi:10.1097/CCM.0000000000001872.
MacLaren R, Jarvis CL, Fish DN. Use of enteral nutrition for stress ulcer prophylaxis. Ann Pharmacother. 2001;35(12):1614-1623. doi:10.1345/aph.1A083
Goodman LS, Gilman A, editors. As Bases Farmacológicas da Terapêutica. New York: McGraw-Hill Education;2018.
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y
Huang HB, Jiang W, Wang CY, et al. Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis. Crit Care. 2018;22(1):20. doi:10.1186/s13054-017-1937-
Alhazzani W, Alenezi F, Jaeschke RZ, et al. Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2013;41(3):693-705. doi:10.1097/CCM.0b013e3182758734.
Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acidsuppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301(20):2120-2128. doi:10.1001/jama.2009.722
Zipursky J, Macdonald EM, Hollands S, et al. Proton pump inhibitors and hospitalization with hypomagnesemia: a population-based case-control study. PLoS Med. 2014;11(9):e1001736. doi:10.1371/journal.pmed.1001736
Hart E, Dunn TE, Feuerstein S, et al. Proton Pump Inhibitors and Risk of Acute and Chronic Kidney Disease: A Retrospective Cohort Study. Pharmacotherapy. 2019;39(4):443-453. doi:10.1002/phar.2235
Lazarus B, Chen Y, Wilson FP, et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016;176(2):238-246. doi:10.1001/jamainternmed.2015.7193
Schoenfeld AJ, Grady D. Adverse Effects Associated With Proton Pump Inhibitors. JAMA Intern Med. 2016;176(2):172-174. doi:10.1001/jamainternmed.2015.7927
Tawam D, Baladi M, Jungsuwadee P, et al. The Positive Association between Proton Pump Inhibitors and Clostridium Difficile Infection. Innov Pharm. 2021;12(1):10.24926/iip.v12i1.3439. doi:10.24926/iip.v12i1.3439
Wise J. Proton pump inhibitors are associated with risk of chronic kidney disease, study finds. BMJ. 2016;352:i128. doi:10.1136/bmj.i128
Amir M, Khan MF. Role of Clinical Pharmacist in Implementation of Stress Ulcer Prophylaxis Protocol: a Single Site Retrospective Study. RADS J Pharm Pharm Sci. 2021;9(4):225-230.
Franchitti M, Berte G, Riva S, et al. Adequação da prescrição de profilaxia para úlcera de estresse na unidade de terapia intensiva: um estudo observacional. Swiss Med Wkly. 2020;35:1-7. doi:10.4414/smw.2020.20322
Jones CA, Betthauser KD, Lizza BD, Juang PA, Micek ST, Kollef MH. Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study. Hosp Pharm. 2022;57(4):510-517. doi:10.1177/00185787211061371.
Ye Z, Reintam Blaser A, Lytvyn L, et al. Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ. 2020;368:l6722. doi:10.1136/bmj.l6722.
von Elm E, Altman DG, Egger M, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806-808. doi:10.1136/bmj.39335.541782.AD
Alshamsi F, Belley-Cote E, Cook D, et al. Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care. 2016;20(1):120. doi:10.1186/s13054-016-1305-6
Lin KJ, Feldman WB, Wang SV, et al. Gastrointestinal prophylaxis for COVID-19: an illustration of severe bias arising from inappropriate comparators in observational studies. J Clin Epidemiol. 2022;151:45-52. doi:10.1016/j.jclinepi.2022.07.009
Zalloum N, Abu Farha R, Awwad O, et al. Inappropriate prescribing of proton pump inhibitors among patients in two Jordanian tertiary health facilities. Trop J Pharm Res. 2016;15(11):2489-95. doi:10.4314/tjpr.v15i11.26
Durand C, Willett KC, Desilets AR. Proton Pump Inhibitor use in Hospitalized Patients: Is Overutilization Becoming a Problem?. Clin Med Insights Gastroenterol. 2012;5:65-76. doi:10.4137/CGast.S9588
Meli M, Raffa MP, Malta R, et al. The use of proton pump inhibitors in an Italian hospital: focus on oncologic and critical non-ICU patients. Int J Clin Pharm. 2015;37(6):1152-1161. doi:10.1007/s11096-015-0178-0
Heidelbaugh JJ, Kim AH, Chang R, et al. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012;5(4):219-232. doi:10.1177/1756283X12437358
Ye Z, Reintam Blaser A, Lytvyn L, et al. Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ. 2020;368:l6722. doi:10.1136/bmj.l6722
Krag M, Perner A, Wetterslev J, et al. Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care Med. 2015;41(5):833-845. doi:10.1007/s00134-015-3725-1
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
Matoso AGB, Almeida FAMT, Paiva L, et al. Proton pump inhibitor indications in a Brazilian tertiary hospital. Rev Assoc Med Bras (1992). 2020;66(7):913-917. doi:10.1590/1806-9282.66.7.913
Bischoff LM, Faraco LSM, Machado LV, et al. Inappropriate usage of intravenous proton pump inhibitors and associated factors in a high complexity hospital in Brazil. Arq Gastroenterol. 2021;58(1):32-38. doi:10.1590/S0004-2803.202100000-07
Cardoso DS, Matos LEQ, Barros IM, et al. Desenvolvimento de um protocolo de inibidor de bomba de prótons na profilaxia de lesão aguda de mucosa gástrica: relato de experiência. Research, Society and Development. 2022;11(8);e25211830865. doi: 10.33448/rsd-v11i8.30865
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