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Steroid Use and Stress Ulcer Prophylaxis for Critical Asthma: A Pairing Worth Reconsidering

March 10, 2022

Corticosteroids are central to treating asthma when it is severe enough to require admission to the pediatric intensive care unit (PICU). With the use of systemic steroids, stress ulcer prophylaxis (SUP) is often initiated with histamine-2 blockers or proton pump inhibitors to reduce the risk of gastric ulcer. But the use of SUP may carry risks as well; these medications are associated with ventilator-associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and thrombocytopenia (refer to references 18-24 in the article). Do the benefits of SUP in critical asthma (CA) outweigh the risks?

Roberts et al (10.1542/peds.2021-054527) from Johns Hopkins All Children’s Hospital, in a study being early-released in our journal this month, share with us the results of their retrospective multicenter study using registry data from the Pediatric Health Information System. The study evaluated more than 30,000 PICU admissions in 42 U.S. children’s hospitals from 2010-2019.  Overall, 10,387 (34.4%) received SUP. While the use of SUP increased over the decade studied, there was significant variation across PICUs (5.9% to 97.2%). Most notably no episodes of gastrointestinal bleeding were recorded, regardless of the use of SUP. The authors also looked to see if there were differences in the rates of gastritis or SUP-related complications. Such events were minimal and rare.

Do the results of this study mean we should reconsider the use of SUP in children with CA? Given that this was a retrospective study, the authors cannot recommend this with 100% certainty but do suggest we be more selective in its use. Just what might be some selective criteria to better target the use of SUP? The authors provide some suggestions well worth considering in the discussion section of their article. Linking to this study is painless and will not stress you and in turn your patients with critical steroid-dependent asthma.

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