In this episode I’ll:
1. Discuss an article about withholding stress ulcer prophylaxis in critically ill patients.
2. Answer the drug information question “Can pancrelipase pellets be given via gastrostomy tube?”
3. Share a resource from Vanderbilt University School of Medicine.
Article
Lead author: Waleed Alhazzani
Published in Critical Care Medicine April 2017
Background
Routine stress ulcer prophylaxis (SUP) in critically ill patients is dogma, but evidence is mounting that questions who actually needs stress ulcer prophylaxis.
As I discussed in episode 134, an update on the 1999 stress ulcer prophylaxis guidelines is very much overdue. ASHP lists the publication date of new SUP guidelines as Spring 2017 but as of this writing, there are only 6 more days left until that deadline passes.
Authors of this study sought to investigate the efficacy and safety of withholding proton pump inhibitors in critically ill patients.
Methods
This was a multi-center, double-blind, randomized controlled trial. The authors randomized adult ICU patients anticipated to be mechanically ventilated for greater than or equal to 48 hours to receive 40 mg of IV pantoprazole daily or placebo.
Exclusion criteria were acute or recent gastrointestinal bleed, used dual antiplatelet agents, medical need for proton pump inhibitor treatment, or already received acid suppression before enrollment.
In addition to this trial, the authors conducted a systematic review and meta-analysis of similar trials.
Results
Ninety-one patients (49 pantoprazole and 42 placebo) from 10 centers in Canada, Saudi Arabia, and Australia were enrolled.
Upper GI bleeding, ventilator-associated pneumonia, and C. difficile infection all occurred more frequently in the pantoprazole group. However none of these differences achieved statistical significance.
In the meta-analysis of 5 similar trials, there was no statistically significant difference in the risk of upper gastrointestinal bleeding, infections, or mortality.
Conclusion
The authors concluded:
Our results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis. Although the results are imprecise, there was no alarming increase in the risk of upper gastrointestinal bleeding; the effect of proton pump inhibitors on ventilator-associated pneumonia and C. difficile remain unclear.
Discussion
The evidence against widespread stress ulcer prophylaxis for critically ill patients continues to grow. Lack of benefit combined with the risk of harm (C. difficile, pneumonia) is a definite concern.
I would like to see some larger trials of pantoprazole vs placebo before considering abandoning stress ulcer prophylaxis. If results from these smaller trials are replicated by the 3 studies discussed in episode 134, I predict that within these next 2 years we will look at stress ulcer prophylaxis in a completely different way.
Drug information question
Q: Can pancrelipase pellets be given via gastrostomy tube?
A: Yes, when mixed with acidic food such as applesauce.
The lumen of the G-tube that empties into the stomach isn’t one large hole the width of the tube. Instead, the distal end of G-tubes have multiple smaller holes that are prone to clogging by medication pellets such as those found in pancrelipase.
A clogged G-tube cannot always be easily replaced, so medications that might produce clogging should be avoided.
The authors of a 2011 study found that pancrelipase mixed in applesauce does not clog the following G-tubes:
Kimberly-Clark MIC Bolus® size 18 Fr and larger
Kimberly-Clark MIC-KEY® 16 Fr and larger
Bard® Tri-Funnel 18 Fr and larger
Bard® Button 18 Fr and larger
The pancrelipase was stirred into applesauce and left to sit for 15 minutes, then pushed at a rate of about 1 mL per second through each G-tube.
Resource
The resource for this episode is the Trauma and Surgical Critical Care Practice Management Guidelines from Vanderbilt University School of Medicine. These guidelines are published on the web and freely available. There are dozens of guidelines covering pharmacology, fluids, nutrition, and more. Their stress ulcer prophylaxis guidelines were updated January 2017, and they recommend famotidine for most patients unless there is a specific indication for pantoprazole.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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