kale SUP

t/f: stress induced ulcers are associated with a prior GI disease

false. not associated with prior GI disease. clinical outcome depends on severity of the current underlying disease

gastric acid secretions are normal except in which diseases?

sepsis and CNS injury (cause increase in gastric acid secretion)

how can you differentiate SUP and PUD

SUP= asymptomatic (indistinguishable from NSAID)

- superficial lesions in fundus and body (acid producing)

- perforations are RARE

- bleeding from superficial capillaries

PUD= characteristic sx

- some deep lesions in antrum and duodenum (not acid producing

- perforations COMMON

- bleeding from one large vessel

Curlings vs Cushings vs Drug induced ulcers

Curling's: burn pts. single lesion in duodenum that goes below muscle

Cushing: head trauma/ increased intracranial pressure. can happen anywhere, may perforate wall of viscus

Drug: looks same as stress ulcer!! dx based on clinical setting

RISK FACTORS FOR SUD

CSLN

critically ill with:

1. coagulopathy (plts <50k, INR>1.5, PTT >2x)

2. shock (<90)

3. chronic Liver disease

Neurocritical pt (brain, hemorrhage)

pathophys of stress induced ulcers

critical illness increases catecholamines and hypovolemia-> lower CO-> hypoperfusion which causes...

lower bicarb, lower blood flow, lower GI motility, acid back diffusion

==== acute stress ulcer

gold standard for stress ulcer dx

endoscopy

for stress ulcers, what do we want to maintain gastric pH above?

want to maintain above 4, ideally above 5-7

pharm options for SUD prophylaxis

H2RAs and PPIs

(want to maintain pH above 4, so sucralfate and antacids arent rlly effective)

H2RAs route for SUD prophylaxis

- via NG tube or PN

- IV push or continuous infusion

continuous infusion is more effective tho! NEED renal dosage adjustments (CrCl <30ml/min)-> give less

H2RAs ADEs

diarrhea

headache, drowsy, fatigue, confusion

thrombocytopenia!!! (4-7 days after initiation)

which SUD tx can lead to thromobcytopenia (less platelets)

H2RAs (also can cause fatigue and drowsiness)

t/f: if platelet count is <50k, you may consider switching PPI to H2RA

false. H2RA is the one that might induce thrombocytopenia

which SUD prophylaxis may be more helpful in pts with erosive esophagitis

PPIs

prophylaxis pantoprazole for SUD

administration and dose

pantoprazole IV: unstable in solution, needs dedicated line w filter. only stable for 12hrs

- 40mg daily

[compare to bleeding ulcer which was 80 bolus then 8mg/hr]

which PPIs are available as suspensions

omep, lanso, eso, panto

PPIs ADEs/ increased risk/ clinical pearls

well tolerated but may have headache, diarrhea, ab pain

risk: c. diff, pneumonia, osteoporosis

omep/eso: phenytoin, warfarin, diazepam (increases levels bc inhibits cyp2c19), also clopidogrel (attenuates/worsens)

t/f: all critically ill pts should be treated with SU prophylaxis

false. adults who are enterally fed and are at low risk for stress related UGIB do not need SUP

when is stress ulcer prophylaxis needed?

pts with 1+ risk factors

- coagulopathy

- shock

- chronic liver disease

- neurocritical

pt has 1+ risk factors and needs SUP. what is different in administration based on if their gut works

EN: give H2RA/PPI EN. if NG then stop suction 2hrs after administration

gut doesnt work: give IV

which SUP needs to be adjusted based on kidney fxn? how do you know when to adjust it?

H2RAs need to be adjusted if CrCl is <30ml/min

- give less

[also remember cimetidine has more DDIs]

dosing for the following for SUP

pantoprazole

esomeprazole

omeprazole

lansoprazole

famotidine

cimetidine

pantoprazole and esomeprazole: 40mg IV/NG/PO qd

omep: 40mg PO or NG qd

lanso: 30mg PO or NG qd

famotidine: 20mg IV/NG/PO BID!!

cimetidine: 300mg IV/PO/NG q6hrs!!!

remember H2RAs need adjustment if CrCl<30

and cimetidine has a lot of DDIs

when are PPIs required OVER H2RAs in SUD

1. recent UGIB

2. hypersecretory states (ex: ZES)

3. erosive esophagitis

4. HP infections

when do you d/c SUP prophylaxis?

- no more risk factors present

- before TO of ICU to prevent inappropriate prescribing