Changing Paradigms in Stress Ulcer Prophylaxis

Obviously any patient that requires mechanical ventilation for 48 hours or has “coagulopathy” should get stress ulcer prophylaxis (SUP) right? maybe not….
when the above risk factors where identified in 1994 by Deborah Cook (N Engl J Med. 1994;330(6):377-81.) and studies validating SUP as an effective means of preventing GI bleeding in critically ill patients were published (Crit Care Med.1993;21:1844-9. and Crit Care Med. 1993;21:19-30 – btw, cimetidine continuous infusion, really?) critical care was quite different than today. Particularly, the emphasis on early enteral nutrition did not really come to fruition until more recently.
In fact, even the 2010 meta-analysis by Paul Marik that supported SUP only found benefit in patients NOT receiving enteral nutrition 
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Recently, several small RCTs have been published challenging the notion that SUP is necessary in modern practice.
The POP-UP trial (CCM 2016) showed no difference in “clinically relevant bleeding” in 214 patients randomized to PPI or placebo (100% received enteral nutrition)
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A 2017 exploratory study in the Journal of Critical Care compared “enteral nutrition vs PPI” in 102 patients and again found no difference in bleeding 
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Finally, another pilot study published last year in CCM, again had similar findings as above in 91 total patients (89% received enteral nutrition.
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the exclusion criteria from these 3 papers are rather mixed but include things like recent GI bleed, dual anti-platelet use and in one case 100 mg prednisone equivalent.
So are these enough data to stop using pharmacological SUP, especially with the possible increased risk of pneumonia and C.diff (see 2018 ICM meta-analysis) or are these data sets just too small? The SUP-ICU trial should give us a better idea, they are expecting completion by August of this year. In the mean time,I know of at least 1 ICU that has already implemented a no SUP for patients being fed policy.
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