Preventing the gastrointestinal consequences of stress-related mucosal disease

Stress-related mucosal disease (SRMD) and subsequent upper gastrointestinal (GI) bleeding remain significant concerns in critically ill patients and place them at a high risk of death. Even under circumstances in which GI bleeding is detected, it is difficult to control. Thus, appropriate preventative therapy is the key to reducing mortality in patients at risk for stress-related ulceration and bleeding. Although several factors (e.g., hypoperfusion of the GI tract, reflux of bile salts) contribute to the development of stress-related ulceration, acid is presumed to be a major contributor to this disease state. Current preventative treatment strategies use histamine(2) receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), which suppress acid secretion, and sucralfate, which provides a protective barrier against acid in the GI tract. For the past several years, H2RAs have been preferentially used over PPIs in the hospital setting because H2RAs are available in liquid and intravenous formulations, easing administration problems in the critically ill. However, extemporaneously compounded oral PPI suspensions and the recently approved intravenous formulations of pantoprazole and lansoprazole have eliminated some of the administration issues previously associated with PPIs. Additionally, study data with PPI formulations suggest efficacy in stress ulcer prophylaxis compared with H2RAs. This article provides an overview of SRMD and compares and contrasts the 3 drug classes (i.e., H2RAs, PPIs, and sucralfate) currently used for prevention of this serious complication observed in critically ill patients.