Stress ulcer prophylaxis guidelines: Are they being implemented in Lebanese health care centers?

Table 1 American Society of Health-System Pharmacists recommendations for stress ulcer prophylaxis

Population	Treatment recommendations	Grade
Non-critically ill medical and surgical patients	Prophylaxis not recommended	B1
Critically ill patients with one of the following:
Coagulopathy (i.e. platelet count of < 50 000 mm3, INR of 1.5)	Prophylaxis recommended	C
Mechanical ventilation for > 48 h		C
History of gastrointestinal ulceration or bleeding within 1 year of admission		D
Glasgow Coma score of ≤ 10		B, D2
Thermal injury to > 35% of body surface area		B, D3
Partial hepatectomy		C, D4
Multiple trauma (injury severity score of ≥ 16)		D
Hepatic or renal transplantation		D
Spinal cord injury		D
Hepatic failure		D
Two or more of the following risk factors: sepsis, ICU stay of greater than 1 wk, occult bleeding lasting at least 6 d, and high-dose corticosteroids (> 250 mg/d of hydrocortisone or equivalent daily)		D
Pediatric patients with one of the following:
Respiratory failure	Prophylaxis recommended	C
Coagulopathy		C
Pediatric Risk of Mortality Score of ≥ 10		C
Thermal injuries		D

¹Strength of evidence = B for general medical and surgical patients with fewer than two risk factors for clinically important bleeding; strength of evidence = D for patients with two or more risk factors;

²Strength of evidence = B for histamine H2-receptor antagonist (H2-RAs); strength of evidence = D for antacids and sucralfate;

³Strength of evidence = B for antacids; strength of evidence = D for H2-RAs and sucralfate;

⁴Strength of evidence = C for H2-RAs; strength of evidence = D antacids and sucralfate. INR: International normalized ratio; ICU: Intensive care unit.

Table 2 Dosage regimens for agents used for stress ulcer prophylaxis

Medication	Adult raNGe
Cimetidine	300 mg qid po, NG, or iv or 50 mg/h by continuous iv infusion
Famotidine	20 mg bid po, NG, or iv or 1.7 mg/h by continuous iv infusion
Ranitidine	150 mg bid po or NG, 50 mg every 6-8 h iv, or 6.25 mg/h by continuous iv infusion
Nizatidine	150 mg bid po or NG
Antacids	30-60 mL po or NG every 1-2 h
Sucralfate	1 g qid po or NG
Omeprazole	40 mg LD then 20-40 mg daily po, NG or iv
Lansoprazole	30 mg daily po, NG or iv
Esomeprazole	20-40 mg daily po, NG or iv
Rabeprazole	20 mg daily po or NG
Pantoprazole	40 mg daily po or NG or iv

LD: Loading dose; NG: Nasogastric tube.

Table 3 General characteristics of the sample (n =1004)

Patients characteristics	n (%)
Gender
Males	527 (52.5)
Females	477 (47.5)
Age (yr, mean ± SD)	54.6 ± 21.2
Unit
ICU	142 (14.1)
IM	468 (46.6)
Surgery	190 (18.9)
CCU	94 (9.4)
Pediatrics	40 (4.0)
OBGYN	28 (2.8)
Others	42 (4.2)
Hospital stay: Median and IQR (d)	4.0 (5.0)1
Acid-suppressant drugs
PPIs	618 (61.6)
Omeprazole	477 (47.5)
Lansoprazole	50 (5.0)
Esomeprazole	5 (0.5)
Rabeprazole	86 (8.6)
H2-RAs	386 (38.4)
Ranitidine	384 (38.2)
Nizatidine	2 (0.20)
Duplicate therapy	0 (0)

¹The median was reported since this variable was positively skewed. ICU: Intensive care unit; IM: Internal medicine; CCU: Critical care unit; OBGYN: Obstetrics and gynecology; IQR: InterQuartile range; PPIs: Proton-pump inhibitors; H2-RAs: Histamine 2 receptor antagonist.

Table 4 Assessment of stress ulcer prophylaxis practice

SUP variable	n (%)
Indication
Non-Candidates for SUP1	673 (67)
Candidates for SUP2	331 (33)
1 major risk factor3	53 (25.2)
2 minor risk factors4	204 (20.3)
7 d stay in ICU and 1 minor risk factor	38 (3.8)
Dose
Appropriate	891 (88.9)
Inappropriate	111 (11.1)
Route
Oral	232 (23.2)
Parenteral	770 (76.8)
Inappropriate5	551 (71.6)
Duration (d)
Median (IQR)	4.0 (5)6
Regimen (dose + route + duration)
Appropriate	124 (12.4)
Inappropriate	880 (87.6)

¹Non-candidates are patients receiving stress ulcer prophylaxis (SUP) without an appropriate indication;

²Candidates are patients receiving SUP with an appropriate indication according to American Society of Health-System Pharmacists guidelines;

³Major risk factors are: coagulopathy, mechanical ventilation > 48 h or history of gastrointestinal ulceration or bleeding within 1 year of admission;

⁴Minor risk factors are all other risk factors listed in Table 1;

⁵Inappropriate route is defined as the use of parenteral drugs when oral drugs can be tolerated;

⁶The median was reported since this variable was positively skewed. ICU: Intensive care unit; IQR: Interquartile range.

Table 5 Assessment of stress ulcer prophylaxis practice per indication n (%)

SUP variable	Candidates	Non-candidates	P-value
Acid-suppressant drugs
PPIs	208 (62.8)	410 (60.9)
H2-RAs	123 (37.2)	263 (39.1)	0.557
Dose
Appropriate	281 (84.9)	610 (90.0)
Inappropriate	50 (15.1)	61 (9.1)	0.004
Route
Appropriate	150 (45.3)	301 (44.7)
Inappropriate	181 (54.7)	372 (55.3)	0.859
Dose and route
Appropriate	124 (37.5)	265 (39.4)
Inappropriate	207 (62.5)	408 (60.6)	0.558
Duration (d)
Median (IQR)	5.0 (7.0)	3.0 (4.0)	< 0.0011
Discharge on SUP
Yes	49 (28.8)	70 (20.9)
No	121 (71.2)	265 (79.1)	0.047

¹P-value derived using the Mann-Whitney U test; P-value remained significant even after controlling for hospital stay. SUP: Stress ulcer prophylaxis; PPIs: Proton pump inhibitors; H2-RAs: Histamine 2 receptors antagonists; IQR: Interquartile range.

Table 6 Assessment of stress ulcer prophylaxis practice per hospital type n (%)

SUP variable	Teaching	Non-teaching	P-value
Indication
Candidates	153 (37.8)	178 (29.7)
Non-candidates	252 (62.2)	421 (70.3)	0.008
Dose
Appropriate	350 (86.4)	541 (90.6)
Inappropriate	55 (13.6)	56 (9.4)	0.038
Route
Appropriate	206 (50.9)	245 (40.9)
Inappropriate	199 (49.1)	354 (59.1)	0.002
Dose and route
Appropriate	178 (44.0)	211 (35.2)
Inappropriate	227 (56.0)	388 (64.8)	0.005
Acid-suppressant drugs
PPIs	266 (65.7)	352 (58.8)
H2-RAs	139 (34.3)	247 (41.2)	0.027
Duration (d)
Median (IQR)1	5 (10)	3 (3.75)	< 0.0011
Discharge on SUP
Yes	53 (26.2)	66 (21.8)
No	149 (73.8)	237 (78.2)	0.248

¹P-value lost significance when controlling for hospital stay. SUP: Stress ulcer prophylaxis; PPIs: Proton pump inhibitors; H2-RAs: Histamine 2 receptors antagonists; IQR: Interquartile range.