LETTER
Stress Ulcer Prophylaxis in Ventilated Patients
Charles E. Schwartz
15 November 1994 | Volume 121 Issue 10 | Pages 816-817
TO THE EDITOR:
I was excited to see the recent study by Prod'hom and colleagues [1] documenting the substantial risk for gastric colonization and "late-onset pneumonia" in patients in intensive care units treated with histamine-2 (H2) blockers for stress ulcer prophylaxis. The elevated gastric pH associated with these agents may also cause vitamin B12 malabsorption, as has been seen with omeprazole [2]. Prod'hom and coworkers' results are especially important when added to those of Cooke and colleagues [3], who showed a remarkably low overall incidence of "clinically important" upper gastrointestinal bleeding in patients in intensive care units, with mechanical ventilation and coagulopathy the only two risk factors identified. Even in these mechanically ventilated patients, the risk associated with H2-blocker prophylaxis appears to outweigh any benefit.
In addition to pneumonia, H2 blockers can also cause acute central nervous system dysfunction [4], including "hallucinations, paranoia, bizarre behavior, delirium, disorientation, depression, (and) mania" [5]. The potential for acute and subacute confusional syndromes associated with these agents continues to be poorly appreciated. The elderly, as well as other patients with clinical and subclinical central nervous system impairment, including those with the human immunodeficiency virus and those with renal impairment, may be at particularly high risk.
With such minor benefit and increasingly compelling evidence of risk, the routine and uncritical use of H2 blockers in the acute medical and surgical settings must stop. Where needed, the use of gastric acid-preserving agents that do not affect the central nervous system, such as sulcralfate, may be ideal.
1. Prod'hom G, Leuenberger P, Koerfer J, Blum A, Chiolero R, Schaller MD, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. Ann Intern Med. 1994; 120:653-62.
2. Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy causes malabsorption of cyanocobalamin (vitamin B12). Ann Intern Med. 1994; 120:211-5.
3. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994; 330:377-81.
4. Freston JW. Cimetidine II. Adverse reactions and patterns of use. Ann Intern Med. 1982; 97:728-34.
5. Drugs that cause psychiatric symptoms. Med Lett Drugs Ther. 1993; 35:65-70.
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