Evaluation of Stress Ulcer Prophylaxis for Patients with Coagulopathy Secondary to Chronic Liver Disease

Background:

Current guidelines recommend stress ulcer prophylaxis (SUP) to reduce the risk of an upper gastrointestinal bleed (GIB) in hospitalized patients with coagulopathy, defined as an international normalized ratio (INR) > 1.5 or a platelet count < 50,000/microliter (uL). Typically INR and platelet count are reliable markers for increased bleed risk, specifically stress related GIB. Patients with chronic liver disease (CLD) however have complicated coagulopathies. The increased INR signifies a decrease in production of hepatically synthesized clotting factors but does not account for the simultaneous decrease of endogenous anticoagulants. Additionally, these patients also have decreased circulating platelets due to portal hypertension induced splenic sequestration and decreased thrombopoietin production yet are able to maintain platelet clotting function through up‐regulation of von Willebrand factor and decreased production of ADAMTS13. These changes result in a fragile but often balanced coagulopathy, therefore the altered INR and platelet count may not place this population at an increased risk for stress related GIB. The goal of this study is to determine if SUP with proton pump inhibitors (PPI) is associated with a decreased risk of GIB in patients with coagulopathies secondary to CLD.

Methods:

This multicenter retrospective study included coagulopathic adult patients admitted from 2008 through 2012 with ICD‐9 codes for CLD. Coagulopathy was defined as a platelet count < 50,000 per uL and or INR > 1.5. Patients who experienced a GlB 48 hours prior to or 24 hours following admission were excluded. The study was approved by the institutional review board of each site.

Results:

Among the 742 included patients 4.3% (22/515) of patients receiving a PPI for SUP and 4.0% (9/227) of patients not receiving a PPI developed a GIB during the index hospital admission. Subgroups in which SUP with a PPI decreased the frequency of GIB were patients in the ICU (n=92, PPI 8.9% vs. No PPI 30.8%, p=0.046), requiring mechanical ventilation (n=56, PPI 12.2% vs. No PPI 57.1%, p=0.015), or receiving vasopressors (n=38, PPI 15.2% vs. No PPI 80.0%, p=0.008). Use of PPI for SUP trended toward significance for patients with a history of GIB (n=95, PPI 2.8% vs. No PPI 13.0%, p=0.09). A secondary analysis excluding patients in the ICU, requiring mechanical ventilation, or on vasopressors identified a GIB rate in the PPI group of 3.3% (14/421) and 2.3% (5/220) in the No PPI group.

Conclusions:

Patients who are coagulopathic secondary to CLD requiring the use of mechanical ventilation, vasopressors, or admission into the ICU appear to benefit from PPI SUP, similar to previous findings in critically ill patient populations. Patients with CLD and a history of GIB may benefit as well. Our results however, do not support the recommendation found in SUP guidelines indicating coagulopathic patients should receive SUP while hospitalized.