Stress Ulcer Prophylaxis in Hospitalized Asthmatics

Abstract

Source: Roberts AR, Roddy M, Wilsey MJ, et al. Stress ulcer prophylaxis for critical asthma. Pediatrics. 2022;149(4):e2021054527; doi:10.1542/peds.2021-054527Investigators from Johns Hopkins All Children’s Hospital, St. Petersburg, FL, conducted a retrospective study to assess trends in the use of stress ulcer prophylaxis (SUP) in children admitted to a PICU with critical asthma and compare rates of gastrointestinal (GI) bleeding, gastritis, gastric ulceration, and SUP-related adverse events among those with and without SUP. For the study, they reviewed data in Pediatric Health Information System (PHIS) database. PHIS includes demographic, encounter, diagnostic, procedure, and pharmacy information on children seen at more than 50 children’s hospitals. Study participants were patients 3-17 years old admitted to the ICU at 42 children’s hospitals with a diagnosis of critical asthma, identified by ICD-9 and ICD-10 codes, from 2010–2019. Only patients with pharmacy orders for systemic corticosteroids and ICU length of stay (LOS) ≥1 day were included. SUP was defined as an order for a histamine-2 blocker (H2B) or proton pump inhibitor (PPI) on the first encounter day. The primary study outcome was major GI bleeding event, and secondary outcomes included gastritis, gastric ulcers, intestinal perforations, and SUP-related adverse events (thrombocytopenia, necrotizing enterocolitis, and C. difficile colitis). Rates of outcomes in patients with or without SUP were compared with chi-square of Fisher’s exact tests. Joinpoint regression was used to evaluate chronologic trends in SUP prescribing for children with critical asthma.Data on 30,177 children with critical asthma were included in the analyses. Study participants had a mean age of 8.3 ±3.8 years, and 66.3% were male; mean LOS was 3.2 ±2.1 days, and 11.3% were treated with mechanical ventilation. Overall, 10,387 (34.4%) children received SUP, with 81.6% of these prescribed H2B and 18.4% receiving PPI. No major GI bleeding events occurred in any study patient. One child receiving SUP was diagnosed with gastric ulceration. There were 32 patients diagnosed with gastritis, with no difference in rates of gastritis in children with or without SUP (rates, 0.11% and 0.10%, respectively; P = 0.706). Among the SUP-related adverse events evaluated, only thrombocytopenia was documented, occurring in 24 children; thrombocytopenia was significantly less common in children treated with SUP (0.05% compared to 0.14% in those not prescribed SUP; P = 0.008). During the study, period rates of SUP for children with critical asthma increased from 25.5% in 2010 to 42.1% in 2019, with a mean annual increase of 1.9% ±6.0%.The authors conclude that no major GI bleeds occurred in children hospitalized with critical asthma during a 10-year period and suggest that SUP may not be routinely warranted in these patients.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Critical asthma (asthma exacerbation) is a common problem treated in pediatric ICUs. SUP has become standard of care for patients receiving prolonged mechanical ventilation, but its use has spread to other disease states, especially those involving systemic corticosteroid therapy.1 However, concerns have arisen that these interventions may not be without significant risks, including ventilator associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and acute thrombocytopenia.2As therapies spread beyond their initial intended use, they may be used to treat disease processes with lower risk, less evidence of positive effect, and to prevent negative outcomes with lower prevalence. Despite 10 years of multicenter data, the current investigators were unable to power their study to test whether SUP could prevent adverse outcomes.However, what is clear is that these negative effects were rare in both the SUP and non-SUP groups. Assuming 100% effectiveness (which is a huge stretch), based on the data presented in the current study, the number needed to treat would be approximately 900 (95% CI, 650, 1,250) for gastritis and 30,000 (95% CI, 5,300, 170,000) for gastric ulceration.Both gastritis and stress ulcers are very rare in children with critical asthma, and the evidence for effectiveness of SUP is poor. Routine use of SUP likely can be avoided in children with critical asthma.