Stress ulcer prophylaxis

To the Editor: In the January 2014 issue, Eisa et al¹ suggested that patients who require prolonged mechanical ventilatory support, ie, for more than 48 hours, should receive stress ulcer prophylaxis. This recommendation came from a study by Cook et al² in 1994, which found a significant increase in the risk of gastrointestinal blood loss in this group of patients. Other studies have shown a different result. Zandstra et al³ found an extremely low rate of stress ulcer-related bleeding in this group in the absence of stress ulcer prophylaxis. Another study⁴ in critically ill patients also found no relationship between stress ulcer incidence and prolonged mechanical ventilatory support. Interestingly, that study found that prolonged use of a nasogastric tube is the major risk factor for developing a stress ulcer.⁴ The explanation for why newer studies did not demonstrate the relationship between mechanical ventilation and stress ulcer development may lie in the result of a meta-analysis by Marik et al,⁵ which showed that stress ulcer prophylaxis may not be required in a patient who receives early enteral nutrition. That practice was not common in the past, including at the time the original study was conducted.

According to current evidence, mechanical ventilation for more than 48 hours does not seem to increase the risk of stress ulcer. The medical community should start questioning the routine practice of stress ulcer prophylaxis in this group of patients. In addition, more studies have identified the adverse effects of acid-suppression therapy in this group of patients, and these effects likely make the harms outweigh the benefits. This notion was confirmed in the most recent meta-analysis by Krag et al.⁶ In summary, the practice of routine stress ulcer prophylaxis in all mechanically ventilated patients will likely change in the future, with more focus on patients who are at higher risk.

To the Editor: In the January 2014 issue, Eisa et al¹ suggested that patients who require prolonged mechanical ventilatory support, ie, for more than 48 hours, should receive stress ulcer prophylaxis. This recommendation came from a study by Cook et al² in 1994, which found a significant increase in the risk of gastrointestinal blood loss in this group of patients. Other studies have shown a different result. Zandstra et al³ found an extremely low rate of stress ulcer-related bleeding in this group in the absence of stress ulcer prophylaxis. Another study⁴ in critically ill patients also found no relationship between stress ulcer incidence and prolonged mechanical ventilatory support. Interestingly, that study found that prolonged use of a nasogastric tube is the major risk factor for developing a stress ulcer.⁴ The explanation for why newer studies did not demonstrate the relationship between mechanical ventilation and stress ulcer development may lie in the result of a meta-analysis by Marik et al,⁵ which showed that stress ulcer prophylaxis may not be required in a patient who receives early enteral nutrition. That practice was not common in the past, including at the time the original study was conducted.

According to current evidence, mechanical ventilation for more than 48 hours does not seem to increase the risk of stress ulcer. The medical community should start questioning the routine practice of stress ulcer prophylaxis in this group of patients. In addition, more studies have identified the adverse effects of acid-suppression therapy in this group of patients, and these effects likely make the harms outweigh the benefits. This notion was confirmed in the most recent meta-analysis by Krag et al.⁶ In summary, the practice of routine stress ulcer prophylaxis in all mechanically ventilated patients will likely change in the future, with more focus on patients who are at higher risk.

To the Editor: In the January 2014 issue, Eisa et al¹ suggested that patients who require prolonged mechanical ventilatory support, ie, for more than 48 hours, should receive stress ulcer prophylaxis. This recommendation came from a study by Cook et al² in 1994, which found a significant increase in the risk of gastrointestinal blood loss in this group of patients. Other studies have shown a different result. Zandstra et al³ found an extremely low rate of stress ulcer-related bleeding in this group in the absence of stress ulcer prophylaxis. Another study⁴ in critically ill patients also found no relationship between stress ulcer incidence and prolonged mechanical ventilatory support. Interestingly, that study found that prolonged use of a nasogastric tube is the major risk factor for developing a stress ulcer.⁴ The explanation for why newer studies did not demonstrate the relationship between mechanical ventilation and stress ulcer development may lie in the result of a meta-analysis by Marik et al,⁵ which showed that stress ulcer prophylaxis may not be required in a patient who receives early enteral nutrition. That practice was not common in the past, including at the time the original study was conducted.

According to current evidence, mechanical ventilation for more than 48 hours does not seem to increase the risk of stress ulcer. The medical community should start questioning the routine practice of stress ulcer prophylaxis in this group of patients. In addition, more studies have identified the adverse effects of acid-suppression therapy in this group of patients, and these effects likely make the harms outweigh the benefits. This notion was confirmed in the most recent meta-analysis by Krag et al.⁶ In summary, the practice of routine stress ulcer prophylaxis in all mechanically ventilated patients will likely change in the future, with more focus on patients who are at higher risk.