Does Stress Ulcer Prophylaxis with a PPI Work?

July 11, 2024

Written by Samuel Rouleau

Spoon Feed
An international, multi-center RCT found that administering pantoprazole to intubated ICU patients lowered the rate of upper GI bleeding compared to placebo.

Give pantoprazole and stress less about GI bleeding
This RCT included 4,821 adult ICU patients undergoing invasive mechanical ventilation. 2,404 were assigned to the placebo group, and 2,417 to the IV pantoprazole group. The two groups had similar baseline characteristics. The median duration of pantoprazole therapy was 5 days. Occurrences of clinically important upper GI bleeding was adjudicated by two physician reviewers and was defined as impacting hemodynamics or leading to therapeutic intervention (blood transfusion, vasopressor initiation, endoscopy, surgery, CT angiogram). In the pantoprazole group, the rate of clinically important upper GI bleeding was 1.0% compared to 3.5% for the placebo group (HR 0.30, 95%CI 0.19 to 0.47). The number needed to treat was 40. 90-day mortality was similar for the two groups (29.1% pantoprazole group and 30.9% control group). Importantly, the rates of ventilator-associated pneumonia (23.2% pantoprazole and 23.8% control group) and C. diff infection (1.2% pantoprazole and 0.7% control group) were essentially equivalent.

How will this change my practice?
This study strengthens my practice of using proton-pump inhibitors (PPI) for ventilated ICU patients when indicated.

• It’s also re-assuring against concerns for increased rates of VAP and C. diff with pantoprazole.
• Nevertheless, PPIs should be discontinued when no longer indicated. Using tools such as FASTHUG have been shown to improve patient outcomes.

Source
Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. Published online June 14, 2024. doi:10.1056/NEJMoa2404245