Stress Ulceration Treatment Complications

Nosocomial pneumonia is the main complication of ulcer prophylaxis treatment.

Nosocomial pneumonia is common in critically ill patients, and remains the leading cause of death. It has been established that the use of anti-acid therapy promotes gastric colonization with pathogenic bacteria, and that aspiration of these bacteria may  cause nosocomial pneumonia (10). The use, therefore, of ranitidine or proton pump inhibitors would be expected to be associated with a higher incidence of GI bleeds, and sucralfate would not. In the Cooke paper (4) there was a 19.1% incidence of nosocomial pneumonia in the ranitidine group compared with 16.2% in the sucralfate group – this was not statistically significant. In the Messori meta analysis (9), ranitidine significantly increased the rate of nosocomial pneumonia over sucralfate. Conversely, neither agent increased the nosocomial infection rate in meta analyses against placebo.

The other side effects of these agents should not be forgotten: ranitidine can cause all kinds of mental status changes, particularly in elderly patients, and has been reported to cause arthralgia and other musculoskeletal pain.

There is some evidence that giving H2 antagonists as a continuous infusion has greater efficacy (in terms of keeping gastric pH >3.5) than as intermittent boluses (11). Interestingly, in the Cooke study (4), randitidine was given as a bolus - 50mg every eight hours and gastric pH was not measured (as this would have unblinded the study).

There have been no quality cost effectiveness analyses on stress ulcer prophylaxis to date.

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