Overview
This lecture discussed the evaluation of stress ulcer prophylaxis (SUP) practices in intensive care units (ICUs), the costs related to inappropriate SUP use, and the role of clinical pharmacists in promoting adherence to clinical guidelines.
Background on Stress Ulcer Prophylaxis (SUP)
- ICU patients are at increased risk of gastrointestinal (GI) bleeding due to stress-related mucosal injury.
- Major SUP risk factors include mechanical ventilation ≥48 hours and coagulopathy.
- PPIs are commonly used for SUP but are frequently prescribed inappropriately, increasing costs and risk of adverse events.
- The ASHP guidelines provide criteria for appropriate SUP use.
Study Design and Groups
- Prospective, non-randomized controlled study in two ICUs (observation group [OG] and guideline group [GG]).
- OG received standard care; GG had SUP management led by a physician and clinical pharmacist using ASHP guidelines.
- Inclusion: Age ≥18, ≥24 hours ICU stay; Exclusion: history of GI cancer/bleeding, gastrectomy, dual antiplatelet therapy, or melena.
Key Findings
- All OG patients received SUP; only 42.6% of GG did (p<0.001).
- GG adherence to SUP indication (100%) and dosage form (100%) was much higher than OG (54.5% and 0%, respectively).
- OG overused IV PPIs even when oral forms were suitable.
- Inappropriate SUP in OG led to an extra cost of $327 compared to GG.
- No GI bleeding or C. difficile infections occurred in either group.
Factors Influencing Appropriate SUP Use
- Proper SUP use correlated with higher illness severity (SOFA, APACHE2 scores), longer ICU stays, lower GCS scores, use of mechanical ventilation, and nasogastric feeding.
- Surgical admissions were more likely to have inappropriate SUP prescriptions.
Impact of Clinical Pharmacists
- Clinical pharmacists improved guideline adherence, reduced unnecessary SUP use, minimized IV PPI misuse, and saved costs.
- Pharmacist-physician collaboration and education enhanced appropriate SUP prescribing practices.
Limitations
- Non-randomized, single-center design limits generalizability.
- Short (6-month) study period; no long-term outcome data.
- Cost analysis focused only on drug expenses.
Key Terms & Definitions
- SUP (Stress Ulcer Prophylaxis) — Measures to prevent GI bleeding in critically ill patients.
- PPI (Proton Pump Inhibitor) — Drugs that reduce stomach acid, used for SUP.
- ASHP Guidelines — Criteria for SUP based on risk factors published by the American Society of Health-System Pharmacists.
- SOFA/APACHE2/GCS — Clinical scores measuring severity of illness and consciousness.
- Mechanical ventilation (MV) — Assisted breathing via a ventilator, a major risk factor for stress ulcers.
Action Items / Next Steps
- Review ASHP SUP guidelines and risk factor criteria.
- Evaluate the role of clinical pharmacists in your ICU or hospital.
- Consider institutional interventions (education, pharmacist involvement) to optimize SUP practices and reduce unnecessary costs.