Stress Ulcer Prophylaxis

Stress ulcer prophylaxis lowers the risk of clinically important upper gastrointestinal bleeding in critical illness, but current evidence shows no clear effect on mortality and some harms. It is therefore given only to patients at high risk, and stopped when the risk passes.

High-risk patients. Mechanical ventilation over 48 hours, coagulopathy (INR over 1.5 or platelets under 50 x 10^9/L), shock, head or spinal injury, burns over 35 percent of body surface, a history of gastrointestinal bleeding in the past year, chronic liver disease, and high-dose corticosteroid combined with an NSAID.

Protective factors. Early enteral feeding lowers risk and is not a substitute for prophylaxis in high-risk patients.

Harms. Possible increase in Clostridioides difficile infection and pneumonia, hypomagnesaemia, interstitial nephritis, and interactions.

First line. A proton pump inhibitor, given once daily.

Alternatives. Famotidine, with dose adjustment for kidney function. Sucralfate is not preferred because of its four-times-daily dosing, interactions with enteral feeding and drugs, and aluminium.

Not indicated. Low-risk patients, such as those ventilated for under 48 hours without other risks.

Special groups.

• Children: omeprazole or pantoprazole 1 mg/kg daily (maximum 40 mg).

• Pregnancy: famotidine or a proton pump inhibitor can be used.

• Kidney impairment: halve the famotidine dose.

• East Africa: where Helicobacter pylori is common, test and treat after any bleed.

• Pantoprazole: 40 mg intravenously or orally once daily.

• Omeprazole or esomeprazole: 40 mg intravenously or orally once daily.

• Famotidine: 20 mg intravenously every 12 hours, or 20 mg once daily when creatinine clearance is under 50 mL/min.

• Treatment of clinically important bleeding: pantoprazole 80 mg intravenous bolus, then 40 mg every 12 hours, with endoscopy.

Monitoring. Check haemoglobin, gastric aspirate or stool for blood, and magnesium. Review the indication every day.

Stop rules. Stop prophylaxis when the patient leaves ventilation, risk factors resolve, enteral feeding is established, or at discharge from intensive care. Do not continue it into ward care without an indication.

Referral and escalation. For a bleed with haemodynamic instability, resuscitate, give the treatment dose, and arrange urgent endoscopy and surgical or radiological backup.

Common errors. Giving prophylaxis to every patient, continuing it after intensive care discharge, and combining clopidogrel with omeprazole.