Should prophylactic PPI be given to intensive care patients at risk for GI bleeding?

Critically ill patients receiving intensive care are at risk of gastrointestinal (GI) stress ulceration. Hence, prophylactic therapy with either histamine H2–receptor antagonists or proton-pump inhibitors (PPIs) is recommended by guidelines. But, should prophylactic treatment (PPI) be given to these patients at risk for GI bleeding?

The findings of a new multicenter trial does not appear to think so, given its conclusion that giving PPI to ICU patients to prevent GI bleeding does not seem to affect mortality.

The European, multicenter SUP-ICU trial published in the New England Journal of Medicine (online Dec. 6, 2018) examined the risks and benefits of PPI treatment. The trial included 3298 patients who had been hospitalized to the ICU for an acute condition and who were at risk for gastrointestinal bleeding. They were randomized to receive 40 mg of intravenous pantoprazole (a PPI) or placebo daily during the ICU stay.

No between-group differences were observed with regard to mortality at 90 days (primary outcome) and the number of clinically important events.

  1. 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died.
  2. At least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole vs 22.6% of those assigned to placebo.
  3. 2.5% of patients in the pantoprazole group had clinically important GI bleeding vs 4.2% in the placebo group.

In view of these findings, the authors recommend that “due to the lower incidence of clinically important upper gastrointestinal bleeding in the ICU, prophylaxis with a PPI, if initiated, should be reserved for seriously ill patients who are at risk for this complication”.

Source: Krag M, Marker S, Perner A, et al; SUP-ICU trial group. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med. 2018 Oct 24. doi: 10.1056/NEJMoa1714919. 

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