Johns Hopkins All Children’s Study Finds Commonly Prescribed Stress Ulcer Prophylaxis for Children with Critical Asthma May be “Unwarranted”
By Randolph Fillmore
Childhood asthma is an increasingly common respiratory condition involving chronic inflammation in the lungs. Inflammation from asthma can cause airways to close, bringing on constant coughing, shortness of breath, and rapid breathing with wheezing or whistling sounds. When asthma attacks are severe requiring hospitalization to the intensive care unit, referred to as “critical asthma” (CA), intravenous steroids and other interventions to treat the underlying inflammation are urgently required.
According to Alexa Roberts, M.D., who recently completed her three-year residency at Johns Hopkins All Children’s Hospital, children hospitalized for CA and admitted to the pediatric intensive care unit (PICU) are commonly prescribed stress ulcer prophylaxis (SUP) to prevent gastrointestinal bleeding that has been previously attributed to corticosteroids.
However, while SUP is routinely and increasingly administered to children receiving corticosteroids for critical asthma in the PICU, the incidence of clinically relevant bleeding and potential risk reduction for bleeding as a result of prophylaxis administration had not been investigated in pediatrics or adults.
“We wanted to describe the trends for SUP prescribing and investigate the rates of clinically relevant GI bleeding, gastritis, and SUP-related complications for those with and without SUP exposure,” Roberts explains. “I was already a little suspicious of the broad way in which SUP has been applied.”
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To get answers, Roberts and her fellow researchers queried the Pediatric Health Information System (PHIS) registry to identify national trends in SUP prophylaxis prescribing over most of a decade, and to determine the rates of major GI bleeding and clinically symptomatic gastritis among children hospitalized for CA.
“We hypothesized clinically relevant GI bleeding and gastritis were rare and no different for those who were and weren’t prescribed SUP,” says Anthony A. Sochet, M.D., M.Sc., an assistant professor of Anesthesiology and Critical Care Medicine at The Johns Hopkins University who is based in the Pediatric Critical Care Medicine Division at Johns Hopkins All Children’s in St. Petersburg, Florida.
Looking into rates of SUP prescribing recorded in the PHIS from 2010 to 2019, the researchers found that, in 2019, SUP prescribing rates were 42.1 percent, with the practice of prescribing SUP having increased by an average of 1.9 percent annually since 2010.
Roberts, Sochet and their Johns Hopkins All Children’s colleagues initiated a retrospective, multicenter cohort study using the Pediatric Hospital Information System registry. The PHIS database contains inpatient, emergency department, ambulatory, surgical, and observational and other encounter-level data from more than 50 not-for-profit, tertiary care pediatric hospitals affiliated with the Children’s Hospital Association.
“We elected to do a national study on this topic and review a registry of thousands of children with critical asthma to get a national picture of variation in care related to SUP and the rate of clinically relevant bleeding events, which is what clinicians are trying to prevent when prescribing these agents,” explains Roberts.
The researchers used available data from 42 children’s hospitals from 2010 to 2019 that included those children 3 to 17 years of age admitted to pediatric intensive care units for CA treatment. Their study, noted as being the largest cohort study to date assessing children hospitalized for critical asthma over a 10-year period, was recently published in the journal Pediatrics.
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