ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, . I. PURPOSE. To ensure safe evidence based utilization of stress ulcer prophylaxis to prevent upper . ASHP therapeutic guidelines on stress ulcer prophylaxis. ASHP Report Stress ulcer prophylaxis. of resuscitative technique) may contribute to clinically. ASHP Therapeutic Guidelines important stress-related bleeding

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It seems as though almost every patient admitted to the hospital in the United States is prescribed either a proton pump inhibitor PPI or a histamine-2 antagonist H 2 A as stress ulcer prophylaxis SUP. Stress ulcers are gastric mucosal erosions that can develop in patients with a serious illness or severe injury. Unlike peptic ulcers, which tend to develop in the antrum or duodenum, stress-related mucosal injuries typically occur gidelines the acid-producing areas of the stomach i.

The mucosal changes of stress-related mucosal injury mainly involve small erosions that do not lead to bleeding but may develop into deeper ulcers, which cause bleeding.

Several factors contribute to stress ulcer formation, including acid hypersecretion; alteration of normal protective mechanisms such as mucus and bicarbonate secretions; release of mediators such as arachidonic acid metabolites, cytokines, and oxygen free radicals; and ischemia to the GI system.

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Large studies have indicated that the strongest risk factors for stress-related GI bleeding are prolonged mechanical ventilation and coagulopathy. Although proven to be highly effective in reducing the risk of both overt and clinically important stress-related mucosal bleeding, prophylactic therapy alone does not decrease the overall mortality rate. Additionally, patients on twice-daily PPI dosing to treat gastroesophageal reflux disease GERD symptoms often are not stepped down to single-daily-dose therapy once they are asymptomatic.

The overuse and misuse of ASDs may result in patient harm and increased costs for the health care system. Stress light of these statistics, SUP continues to be overprescribed.

The toxin produced by C difficilean anaerobic, spore-forming, gram-positive bacterium, is a major cause of diarrhea and colitis in hospitalized patients that has increased in incidence, severity, and mortality in recent years.

Approximately 3 million cases occur annually in the U. Despite better control of antibiotic prescribing and improvements in hospital hygiene, the number of CDI cases continues to rise.

Antibiotic use is the biggest risk factor for the development of CDI, but it often cannot be avoided in patients with infections. A less common but more modifiable risk factor is the use of ASDs in hospitalized patients in whom these drugs are not indicated.

SHP EPORTR A ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis

Gastric acid is a nonspecific protective mechanism against ingested pathogens. The stomach is theraeutic free of bacteria, with the exception of Helicobacter pyloriwhich is uniquely equipped to deal asshp gastric acidity.

The vegetative cells of C difficileunlike the spores, are usually killed in the low-pH environment of the stomach; however, they have been found to remain viable in the gastric contents of patients taking ASDs. Research in animal models has shown that C difficile spores transform into vegetative cells within 1 hour of ingestion.


It is plausible that this transformation may occur in the stomach if the pH is higher or in the case of slower gastric transit times. A recent retrospective cohort study found that recurrent CDI was more common in patients exposed to PPIs than in unexposed patients Although results of investigations have been inconsistent, several studies have found an association between the use of ASDs and an increased risk of respiratory tract infections and CAP.

The guideliness increase in the risk of pneumonia associated ulcdr PPIs was observed in the first week of use.

As with enteric infections, ASDs are thought to increase the risk of pneumonia by inhibiting the secretion of gastric acid, thus allowing bacterial overgrowth and colonization. Bacteria may then be translocated to the lungs orophylaxis aspiration. Patients over 65 years of age are at increased risk for pneumonia due to ASDs. Both Campylobacter and Salmonella are acid-sensitive microbes. Parasitic infections have been linked to acid suppression as well, especially giardiasis and strongyloidiasis.

Drug interactions guidelunes another concern with acid suppression. Medications with pH-dependent absorption i. The potential interaction between PPIs and clopidogrel has attracted attention because of possible serious adverse effects. Several cases of patients with hypomagnesemia and subsequent hypokalemia and hypocalcemia who presented with life-threatening symptoms requiring hospitalization have been reported.

Most of these cases were asho with long-term PPI use.

Ashp therapeutic guidelines on stress ulcer prophylaxis. am j health-syst == – Kominkowy Świat

The mechanism of this adverse effect is unknown. In patients with PPI-induced hypomagnesemia, no apparent magnesium malabsorption or renal magnesium wasting has occurred. The use of PPIs for 12 months or longer has been associated with vitamin B 12 deficiency, particularly in elderly patients.

Poor absorption of guidelinees iron prophylaxjs also been linked to PPI therapy, but current data are weak. Gastric acid facilitates the absorption of nonheme iron by reducing ferric iron to the more soluble ferrous form, and also enhances iron-salt dissociation from ingested food. Long-term Ilcer use has been associated with an increased incidence of fractures.

Possible mechanisms include decreased absorption of calcium in a more alkaline gastric environment and impairment of bone remodeling due to decreased osteoclast activity, leading to inhibited microfracture repair. Physicians are encouraged to weigh the risks and benefits of PPI use in vulnerable patients. If calcium supplements are prescribed to PPI users, they should be in a soluble form, such as citrate, rather than carbonate.

The current therapeutic guidelines were published inwith an update in progress at this writing. Prophylaxis is also advised for ICU patients with at least two of the following risk factors: Efforts by clinicians to curb the use of ASDs in non-ICU patients can prevent significant patient morbidity and reduce both hospital costs and priphylaxis to the overall health care system.



It is important to carefully weigh the risks and benefits of ASDs before using these medications in the inpatient setting. Special consideration should be given to patients already at pgophylaxis for pneumonia, such as the elderly, those with chronic lung disease, and those taking immunosuppressants. Every effort should be made to critically assess acid-suppression therapy in inpatients and to discontinue therapy whenever possible. Ulccer SUP is indicated, the patient should receive the lowest dose possible.

Pharmacists can help stem the use of ASDs by identifying patients who are inappropriately prescribed these medications, and they can be instrumental in educating physicians about which patients should receive SUP.

Pharmacists involved in processing discharge medications can help ensure that patients are not sent home on acid-suppressive therapy without an appropriate indication. Unfortunately, the measures taken to prevent stress ulcers in hospitalized patients have created a new problem, and by working together the health care team can help prevent further unnecessary morbidity by enforcing guideline recommendations at their institution.

ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. Zuckerman GR, Shuman R. Therapeutic goals and treatment options for prevention of stress ulcer syndrome.

Gastrointestinal hemorrhage in patients in a respiratory intensive care unit. Stress-related mucosal disease in the intensive care unit: Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Overutilization of proton pump inhibitors: Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Why do physicians prescribe stress ulcer prophylaxis to general medicine patients?

Proton pump inhibitors and risk for recurrent Clostridium difficile infection.

Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Health care costs and mortality associated with nosocomial diarrhea due to Clostridum difficile. Clostridium difficile —associated diarrhea. Cunningham R, Dial S. Is over-use of proton pump inhibitors fuelling the current epidemic of Clostridium difficile -associated diarrhoea?

Acid inhibition and infections outside the gastrointestinal tract. Use of acid-suppressive drugs and risk of pneumonia: Recurrent community-acquired pneumonia in patients starting acid-suppressing drugs. Sheen E, Triadafilopoulos G. Adverse effects on long-term proton pump inhibitor therapy. Proton pump inhibitor use and enteric infections. American Society of Health-System Pharmacists. Accessed September 19, Prophylactic Therapy Although thefapeutic to be highly effective in reducing the risk of both prophylaxiis and clinically important stress-related mucosal bleeding, prophylactic therapy alone does not decrease the overall mortality rate.

Risks of Therapy CDI: To comment on this article, contact rdavidson uspharmacist. Gudelines in whole or in part without permission is prohibited.