Question of the Week: February 4, 2000


Should stress ulcer prophylaxis with H2 blockers be discontinued after enteral feeding begins?

Answer:  No.

Although enteral feeds into the gastric space are considered relatively protective, they are not sufficient as prophylaxis against stress-induced gastric ulceration in critically ill patients.  This was most recently shown in the large multicentre study1 that assessed the effect of sucralfate versus ranitidine on stress ulcer prophylaxis.  Analysis within this study showed that gastric feeding on its own was not of sufficient protection.  In addition, and as expected, enteral feeds into the duodenum or jejunem do not provide any protection.

At present, stress ulcer prophylaxis is recommended for any patient in the intensive care who presents with at least one of the following risk factors:

  •     mechanical ventilation of expected duration > 72 hours
  •     coagulopathy (not including drug therapy such as anticoagulation)
  •     shock
  •     severe sepsis
  •     head trauma
  •     spinal cord injury/quadraplegia
  •     severe burns (> 30%)
  •     multiple organ failure


The drug of choice for prophylaxis is an H2 blocker, most commonly ranitidine, either by the intravenous or enteral route.  Second choices would include sucralfate, which must be administered into the gastric space for patients, and proton pump inhibitors, such as omeprazole and pantoprazole for patients with increased risk factors.

References:

Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, Peters S, Rutledge F, Griffith L, McLellan A, Wood G, Kirby A, Tweeddale M, Pagliarello J, Johnston R.  (1998) A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation.  NEJM, 338(12):791    
 
 
 



Lynne Kelly
Pharmacist, CCTC
February 4, 2000
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