Gut protection: why and how?

Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients

OBJECTIVE

To evaluate the use of proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in critically ill adults.

DATA SOURCES

Computerized biomedical literature search of MEDLINE (1966-June 2002) was conducted using the MeSH headings proton-pump inhibitor, ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts.

DATA SYNTHESIS

Traditional medications used for stress ulcer prophylaxis include antacids, histamine(2) receptor antagonists (H(2)RAs), and sucralfate. Few studies have evaluated PPIs for stress ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH > or =4.0. PPIs are safe and seem to be as efficacious as H(2)RAs or sucralfate for prevention of bleeding from stress-related mucosal damage (SRMD) and they may provide cost minimization. The small patient populations limit the results of comparative studies.

CONCLUSIONS

Available data indicate that PPIs are safe and efficacious for elevating intragastric pH in critically ill patients. PPIs should be used only as an alternative to H(2)RAs or sucralfate since the superiority of PPIs over these agents for preventing SRMD-associated gastrointestinal bleeding has not been established. Additional comparative studies with adequate patient numbers and pharmacoeconomic analyses are needed before PPIs are considered the agents of choice for stress ulcer prophylaxis.