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January 16, 2013
New Scoring System Suggested for Using Acid-Suppressives Outside the ICU

Boston—While acid-suppressive medications are routinely prescribed to critically ill patients in hospital intensive care units (ICU) to reduce their risk of developing stress ulcers and gastrointestinal (GI) bleeding, the use of those medications in non-ICU patients is not as clear-cut.

In a report published online by the Journal of General Internal Medicine, researchers from Beth Israel Deaconess Medical Center (BIDMC) point to the "lack of evidence to guide physicians in prescribing acid-suppressive medications for stress ulcer prophylaxis in patients outside the ICU" and discuss a new scoring system to better identify non-ICU hospital patients who are at risk for GI bleeding. The selective use of acid-suppressive medications reduces costs and avoids unnecessary side effects, the authors note.

"Current guidelines recommend against the routine use of acid-suppressive medication to prevent stress ulcers in non-ICU patients. Moreover, there is growing evidence that these drugs are associated with an increased risk of complications, including hospital-acquired pneumonia and clostridium difficile," explains first author Shoshana Herzig, MD, an investigator in BIDMC's Division of General Medicine and Primary Care and instructor in medicine at Harvard Medical School. "Despite these factors, acid-suppressive medications continue to be used indiscriminately in non-ICU patients."

For the study, investigators examined records of 75,723 patients at Beth Israel Deaconess Medical Center over a 4-year period. Patients were excluded if they had been admitted to the hospital with an existing case of GI bleeding, if they developed a bleed within a day of admission or if they were scheduled to undergo cardiac catheterization, which exposes them to high levels of medications that impair clotting. Of the remaining group, 203 patients had GI bleeding.

A statistical model "allowed us to identify certain factors associated with significantly higher rates of bleeding," Herzig explains. "Our analysis revealed a number of independent risk factors that appeared to be associated with GI bleeds among non-ICU patients. These included being over age 60; being male; having liver disease, acute renal failure or sepsis; use of anticoagulant medication; preexisting clotting disorders; or being hospitalized on the internal medicine service.

The number of patients in each risk category that would need to be treated with acid-suppressive medication to prevent one GI bleed was then calculated. "In the remaining patients, we determined that medication could be safely withheld," Herzig notes, suggesting future studies are needed to reproduce the data.

"In this large cohort of non-critically ill hospitalized patients, we identified several independent risk factors for nosocomial gastrointestinal bleeding. With further validation at other medical centers, the risk model derived from these factors may help clinicians to direct acid-suppressive medication to those most likely to benefit," the authors write.



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