Recommendations for Stress Ulcer Prophylaxis in Critically Ill Adults: A Contextualized Clinical Practice Guideline From the Saudi Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine, Endorsed by the Kuwait Anesthesia and Critical Care Society

BACKGROUND: Critically ill adults are at risk for stress-related upper gastrointestinal bleeding (UGIB). Regional variations in gastrointestinal bleeding incidence, infection epidemiology, formulary access, and the relative value placed on bleeding versus infection outcomes by patients and clinicians necessitate contextualized recommendations. This guideline provides regionally adapted, evidence-based recommendations for the use of stress ulcer prophylaxis (SUP) in Saudi Arabia, Kuwait, and the Nordic countries using the GRADE-ADOLOPMENT methodology.

METHODS: A multidisciplinary panel from both regions prioritized PICO questions and ranked outcomes by patient importance. The 2024 Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) guideline served as the source guideline and was evaluated for credibility; contextual fit in Saudi Arabia, Kuwait, and the Nordic countries; and alignment with the GRADE methodology. Evidence profiles and Evidence-to-Decision frameworks were adapted or developed, incorporating updated data, local epidemiology, drug access, and health system variables such as equity, cost, and feasibility.

RESULTS: The panel adopted the following five recommendations. In critically ill adults with coagulopathy, shock, or chronic liver disease, the panel suggests using SUP over no SUP (conditional recommendation; moderate certainty). In enterally fed patients at high risk of UGIB, the panel suggests using SUP over no SUP (conditional recommendation; very low certainty); in those at low risk, the panel suggests not using SUP (conditional recommendation; very low certainty). For patients receiving SUP, the panel suggests using a proton pump inhibitor (PPI) or a histamine-2 receptor antagonist (H2RA) rather than sucralfate (conditional recommendation; low to moderate certainty) and suggests enteral or intravenous administration based on clinical feasibility (conditional recommendation; very low to low certainty). In critically ill adults receiving SUP, low-dose PPI or H2RA therapy should be used rather than high-dose regimens (best practice statement; not GRADEd). Regarding SUP discontinuation, the panel suggests discontinuing SUP in critically ill adults with resolved risk factors for UGIB (conditional recommendations; very low certainty) and in critically ill adults without UGIB risk factors but receiving SUP prior to intensive care unit (ICU) admission in the absence of an active indication (conditional recommendations; very low certainty). Differences in drug availability, ICU discharge practices, and health equity considerations shaped the panel's judgments and highlighted key implementation challenges.

CONCLUSION: This guideline offers five context-specific, evidence-informed recommendations for SUP in critically ill adults in Saudi Arabia, Kuwait, and the Nordic countries. While grounded in the health system realities of these regions, the recommendations may inform practice in other settings with similar ICU structures and resource contexts. The panel also identified key research priorities to address remaining evidence gaps and support future updates.