Laird Harrison

January 16, 2014

SAN FRANCISCO — Critically ill patients who receive stress ulcer prophylaxis suffer more adverse events with proton pump inhibitors (PPI) than with histamine 2 (H2) receptor antagonists, a new study shows.

"There is overprescription of proton pump inhibitors," said Zerihun Bunaye, MD, an internist at Mercy Hospital in St. Louis, Missouri.

Critically ill patients can develop bleeding caused by stress ulceration, so clinicians often prescribe a PPI or H2 receptor antagonist as prophylaxis. But these medications come with a risk for adverse events. Dr. Bunaye and his team wanted to determine whether one is more dangerous than the other.

He presented the results here at the Society of Critical Care Medicine 43rd Critical Care Congress.

The researchers looked at the records of patients admitted to a 54-bed medical-surgical intensive care unit (ICU) from July 2009 to February 2013.

Of the 14,280 patients who received stress ulcer prophylaxis, 5718 were excluded because they were on acid suppression prior to admission, did not receive stress ulcer prophylaxis in the ICU, or received both a PPI and H2 receptor antagonist.

Of the remaining 8562 patients, 3681 (43%) received a PPI and 4881 (57%) received an H2 receptor antagonist.

The difference in the size of the 2 treatment groups was statistically significant (P < .0001). "If you're in the ICU, you're more likely to be prescribed PPI," Dr. Bunaye explained.

However, the researchers found that stress ulcer prophylaxis was indicated in only 32.3% of patients in the PPI group and 37.8% of patients in the H2 receptor antagonist group (P < .0001). Indications for this therapy include duodenal ulcer, gastric ulcer, Helicobacter pylori infection, erosive esophagitis, mechanical ventilation, coagulopathy, and gastric reflux disease.

The increased risk for adverse events in the PPI group was also significant.

Table. Adverse Event Rates in Patients Receiving Prophylactic Therapy

Adverse Event PPI Group, % H2 Receptor Antagonist Group, % P Value
Gastrointestinal bleeding 4.70 1.10 <.0001
Clostridium difficile infection 1.90 1.30 .02
Nosocomial pneumonia 0.29 0.26 .8
30-day mortality 6.00 3.70 <.0001


"The mortality caught my eye," said session moderator Joshua Roberts, PharmD, senior clinical pharmacist at the University of California, Davis Medical Center. "Are you going to change your procedures?" he asked.

Dr. Bunaye said that more research is needed before making any changes.

Erik Abel, PharmD, a specialty pharmacist at the Ohio State University Wexner Medical Center in Columbus, asked how clinicians reacted to the information about excessive PPI prescription.

"We flag it so we don't prescribe it unnecessarily," Dr. Bunaye said.

Dr. Abel also wanted to know if the researchers had adjusted the statistics to control for severity of illness.

"That needs to be done," said Dr. Bunaye. "This is just a call for further study."

Dr. Bunaye, Dr. Roberts, and Dr. Abel have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 43rd Critical Care Congress: Abstract 894. Presented January 11, 2014.


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