Benefits and risks of routine use of proton pump inhibitors at the intensive care unit

Stress-related mucosal disease (SRMD) is present in nearly all critical ill patients. SRMD leads to an elevated risk of upper gastrointestinal (GI) bleedings, a potentially life-threatening complication associated with a mortality rate of about 30%. This led to the recommendation for stress ulcer prophylaxis in critically ill patients, especially to those with risk factors for GI bleeding such as mechanical ventilation or coagulopathies. Proton pump inhibitors (PPI) effectively prevent gastrointestinal bleedings in critically ill patients at the intensive care unit (ICU). Large meta-analyses including up to 1720 patients from 14 clinical trials revealed that PPI seem to be more effective than histamine 2 receptor antagonists (H2RA) in preventing clinically significant upper GI bleedings in critically ill patients, although they did not reduce overall mortality in ICU patients. Moreover, recent studies revealed that the routine use of PPI at the ICU can be associated with adverse events such as a significantly increased risk of infectious complications, especially of nosocomial pneumonia and Clostridium difficile--associated diarrhea (CDAD). Likewise, PPI can be toxic for both the liver and the bone marrow, and some PPI show clinically relevant interactions with important other drugs like clopidogrel. Therefore, the agent of choice, the specific balance of risks and benefits for individual patients as well as the possible dose of PPI has to be chosen carefully. Alternatives to PPI prophylaxis include histamine receptor blockers and/or sucralfate. Instead of routine PPI use for bleeding prophylaxis, further trials should investigate risk-adjusted algorithms, balancing benefits and threats of PPI medication at the ICU.