Limited data for non-ICU patients demonstrate an increased bleeding risk in the presence of ischemic heart disease, chronic renal failure, mechanical ventilation, or prior ICU stay.11 One study of 17,707 general medical patients found a low overall incidence (0.4%) of overt or clinically important GI bleeding, mainly in patients treated with anticoagulants without a mortality difference related to bleeding events.4
The 1999 American Society of Health System Pharmacists (ASHP) Therapeutic Guidelines on Stress Ulcer Prophylaxis reviewed extensive data by level of evidence to identify clinical indicators of patients at higher risk (see Table 2, p. 31).10 The bottom line is that stress-related bleeding depends on the type and severity of illness. Independent risk factors for critically ill patients include mechanical ventilation or coagulopathy. Stable general medical inpatients are at very low risk of clinically significant GI bleeding.
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Endoscopic view of a human stomach developing a bleeding ulcer.
Clinical predictors help define patients at the greatest risk of SRMB. However, to be meaningful, SUP must improve clinical outcomes. Despite extensive studies on the efficacy of pharmacologic agents in the prevention of significant bleeding, several trials do not show a benefit of SUP over placebo, even in patients with major risk factors.4,12,13 Other independent studies and meta-analyses demonstrate that H2-receptor antagonists (H2RAs) prevent ICU bleeding, reducing events by approximately 50%.10 Of all the available prophylactic agents, H2RAs are FDA-approved for this use, proton pump inhibitors (PPIs) are likely as effective, and both are well-tolerated. However, data suggest that the use of AST is associated with C. difficile-associated disease, hip fracture, and pneumonia.
Outside of the ICU, there is no difference in de novo GI bleeding among general medical patients prescribed SUP. The ASHP guidelines thus conclude there is no indication for SUP in stable, general medical inpatients.10
Prevention Strategies
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Endoscopic view of a human stomach developing a bleeding ulcer.
A subset of seriously ill patients has an increased risk for significant SRMB, but ideal prevention is not well-defined. As noted in the ASHP guidelines, “prophylaxis does not necessarily prevent bleeding in patients with documented risk factors, and the efficacy of prophylaxis varies in different patient populations.”
Given the effect of SRMB, it is reasonable to provide preventive agents to subgroups of critically ill patients with significant risk factors of mechanical ventilation for more than 48 hours and underlying coagulopathy. Studies report that judicious SUP prescription when these risks are present reduces cost without increasing morbidity or mortality in the ICU.14
Back to the Case
Our case addresses a patient in both an ICU and general medical setting. Based on his lack of risk factors for significant GI bleeding, SUP was not indicated. In this case, the patient improved. Had he developed ventilatory failure requiring intubation, the risk of clinically important GI bleeding would have approached 4%, and H2RA prophylaxis would have been recommended. Although the optimal length of prophylaxis is unknown, SUP likely can be discontinued on transfer out of the ICU, as clinical stability is associated with a substantially lower risk of clinically important bleeding.
Bottom Line
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Literature supports the limited use of SUP in hospitalized medical inpatients. SUP can be reserved for critically-ill patients with major risk factors, including prolonged mechanical ventilation or coagulopathy. TH
Dr. Wright is associate professor and head of the section of hospital medicine of the Department of Medicine at the University of Wisconsin School of Medicine and Public Health.