Stress Ulcer Agents
An article published this year in the American Journal of Health-Systems Pharmacy defined stress ulcers as “acute superficial inflammatory lesions of the gastric mucosa induced when an individual is subjected to abnormally high physiologic demands.”1
These stress ulcers are believed to be caused by an imbalance between gastric acid production and the normal physiologic protective mucosal mechanisms in the gastrointestinal (GI) tract. Reduction of blood flow to the gastric mucosa may also lead to ischemic damage to the GI mucosa.
This new intranasal spray delivery device for hemostatic treatment of oozing blood and minor bleeding of accessible capillaries or small venules, was recently FDA approved. Some high-risk groups require rapid intervention to curb epistaxis (e.g., the elderly) to prevent complications or life-threatening events. The Thrombin-JMI intranasal spray delivery device works directly by clotting fibrinogen. It should not to be used on large blood vessels or injected. The kit is supplied in a package that includes a 20,000 IU vial of thrombin with 20 mL diluent, a spray pump, and actuator. It is expected to be available in EDs and trauma centers by year’s end.
Selzentry (maraviroc, Pfizer). FDA-approved on Aug. 6, it is the first agent in a new class of anti-HIV drugs known as HIV entry blockers. This agent holds promise for HIV-positive patients who no longer respond to other anti-HIV drugs (e.g., protease inhibitors, reverse transcriptase inhibitors). Maraviroc is effective against a specific strain of HIV known as CCR5-tropic HIV-1. Maraviroc binds to CCR5, blocking HIV from binding to this receptor. When CCR5 is unavailable, CCR5-tropic HIV cannot engage a CD4 cell to infect it. In clinical trials, patients were tested for the presence of CCR5-tropic HIV-1 using a co-receptor tropism assay, Trofile (MonogramBiosciences Inc.), which predicts a patient’s likelihood for response to maraviroc. Maraviroc received a priority review at the FDA and a priority review in the European Union. Monogram Biosciences released Trofile on Aug. 6 to coincide with the commercial availability of maraviroc. SCH-D (vicriviroc, Schering-Plough) is another entry blocker. It is in Phase III clinical trials.
The development of stress ulcers, or stress-related mucosal disease (SRMD), occurs in 75% to 100% of critically ill patients within 24 hours of intensive care unit (ICU) admission. Although bleeding risk has decreased over the years, mortality from stress-related bleeding nears 50%. According a peer-reviewed guideline from the American Society of Health-System Pharmacists (ASHP), indications for SRMD in the ICU setting include:2
- Coagulopathy;
- Mechanical ventilation longer than 48 hours;
- History of GI ulceration or bleeding within one year of the current admission;
- Glasgow Coma score of 10 or less (or if unable to obey simple commands);
- Thermal injury to more than 35% of the body surface area;
- Partial hepatectomy;
- Multiple trauma;
- Transplantation perioperatively in the ICU;
- Spinal cord injury;
- Hepatic failure; and
- Two or more of the following risk factors: sepsis, ICU stay of a week or longer, occult bleeding for more than six days, or high-dose corticosteroids (more than 250 mg a day of hydrocortisone or the equivalent).
Other risk factors for SRMD in ICU patients include multiorgan failure, chronic renal failure, major surgical procedures, shock, and tetraplegia.3,4
Recommended SRMD prophylaxis agents should be institution-based, taking into account the administration route (e.g., functioning GI tract), daily dosing regimens, adverse effect profile, drug interactions, and total costs. Classes that can be used include sucralfate, antacids, H2 receptor antagonists (H2RA), and proton-pump inhibitors (PPIs).
