1. Every patient admitted to ICU does not need stress ulcer prophylaxis
especially those on normal diet; it should be prescribed on a case-by-case
basis.
2. Prescribe stress ulcer prophylaxis for patients at high risk of
gastrointestinal bleeding as follows:
Bleeding diathesis (e.g., platelet count <50,000 per m3, an
international normalized ratio [INR] >1.5, or a partial
thromboplastic time [PTT] >2 times the control value).
Mechanical ventilation for >48 hours especially those who are not
being enterally fed.
Chronic liver disease.
History of GI ulceration or GI bleeding within the past year.
Traumatic brain injury, traumatic spinal cord injury, or burn injury.
Patients with two or more of the following minor criteria:
● Sepsis.
● ICU stay more than one week.
● Occult GI bleeding for six or more days.
● Glucocorticoid therapy (more than 250 mg hydrocortisone or the
equivalent).
On Nonsteroidal anti-inflammatory or antiplatelet agent.
3. Select one of the following agents.
3.1. Histamine-2 receptor antagonist (Ranitidine)
If CrCL ≥ 50 mL/min:
● Ranitidine: 150 mg q 12 hrly orally.
● Ranitidine: 50 mg every 6 – 8 hours IV.
If CrCL< 50 mL/min:
● Ranitidine: 150 mg once daily orally
● Ranitidine: 50 mg once daily IV.
3.2. Proton pump inhibitors
Pantoprazole 40 mg IV/Oral once daily only if there is evidence/history of
Peptic Ulcer disease or UGI Bleeding.
3.3. Sucralfate and antacids are not recommended for stress ulcer
prophylaxis.
3.4. Switch to oral route whenever possible.
3.5. Stress ulcer prophylaxis may be discontinued once the original
stressors are removed.
Further Readings:
1. Ye, Z., Blaser, A. R., Lytvyn, L., Wang, Y., Guyatt, G. H., Mikita,
J. S., ... & Siemieniuk, R. A. (2020). Gastrointestinal bleeding
prophylaxis for critically ill patients: a clinical practice guideline. Bmj,
368.
2. Young, P. J., Bagshaw, S. M., Forbes, A. B., Nichol, A. D., Wright,
S. E., Bailey, M., ... & Rowan, K. M. (2020). Effect of stress ulcer
prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on
in-hospital mortality among ICU patients receiving invasive mechanical
ventilation: the PEPTIC randomized clinical trial. Jama, 323(7), 616-626.
3. Dellinger, R. P., Levy, M. M., Carlet, J. M., Bion, J., Parker, M.
M., Jaeschke, R., ... & International Surviving Sepsis Campaign
Guidelines Committee. (2008). Surviving Sepsis Campaign: international
guidelines for management of severe sepsis and septic shock: 2008. Critical
care medicine, 36(1), 296-327.
