What’s up with SUP? Update on the use of stress ulcer prophylaxis

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Lauren Igneri
Critical care pharmacist and proud Rutgers University graduate. Enjoys rock climbing, cycling, travel, and lively discussions on the finer points of pharmacokinetics and critical care over a beer with friends.

The Pre-brief

It is estimated that 2.5% of critically ill patients experience GI bleeding due to stress ulceration resulting from alterations in blood flow to the gut and subsequent mucosal breakdown. Stress ulcer prophylaxis (SUP) has been reported to be prescribed in up to 70% of critically ill patients, with PPIs being most common followed by H2 Receptor Antagonists (H2RAs), sucralfate, and antacids. SUP is often incorporated into admission order sets or intubation pathways which likely accounts for high prescribing rates. Previous meta-analyses have concluded that PPIs are more effective than H2RAs for preventing clinically important bleeding, but SUP, especially with PPIs may be associated with increased nosocomial infections.

A systematic review and meta-analysis including 72 trials with total of 12,660 patients was performed and published in 2020. Here’s the updated scoop on SUP:

The Debrief

  • SUP should be reserved for those at high and highest risk for developing clinically important and overt upper gastrointestinal bleeding 
    • PPIs may reduce the risk of clinically important and overt GI bleeding to a greater extent than H2RAs
    • SUP likely increases the risk of developing pneumonia
  • Local prescribing practices and order sets should be updated to risk stratify patients in order to minimize the risk to benefit ratio of using SUP


  1. The PEPTIC investigators. Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital mortality among ICU patients receiving invasive mechanical ventilation: The PEPTIC randomized clinical trial. JAMA. 2020; 323(7):616-626.
  2. Wang Y, Ye Z, GE L et al. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis. BMJ. 2020; 368: l6744.
  3. Ye Z, Blaser AR, Lytvyn L et al. Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ. 2020; 368:I6722


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