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Thank you for your interest in our article.¹ You raise a number of issues, and we will reply to them sequentially.

We agree that the pantoprazole group may have had some degree of selection bias, as these patients seem to have been sicker, as indicated by their significantly higher APACHE II scores. Whether this had any impact on outcome, however, remains unknown for 2 reasons. As we noted in the article, no prior studies have specifically identified acuity as a risk factor for upper gastrointestinal bleeding (UGIB) in the critical care setting, although acuity might seem to be an obvious predisposing factor for this complication.^2,3 Also, despite the significant difference in acuity scores between the groups, except for the incidence of UGIB, no other differences in outcome parameters were identified, suggesting minimal if any clinical significance of their conditions.

With regard to your second point, we intentionally chose to limit this study to patients receiving mechanical ventilation, as this is a well-defined population and our conclusions clearly refer only to this population. However, on the basis of the existing literature and pathophysiology of UGIB in critically ill patients, it would seem reasonable on clinical grounds to extrapolate these results to other high-risk patients in the absence of contradictory data.

In your third statement, you point out that our definition of UGIB differs from the definition used in other studies. But this point is specifically acknowledged in our article. Our purpose was not to compare our method of assessing UGIB with the methods of other investigators, but to assess the incidence of this complication using the 2 classes of drug compared. As we noted in our article, we believe that the definition of UGIB as employed by Project Impact, although imperfect, is practical and unlikely to miss clinically important episodes of bleeding. We also point out that no standard method has been used to define UGIB in previously published studies.^2–7

We certainly agree with your final statement that the role of PPIs as a first-line therapy is unclear. The 2 prospective studies that have addressed this issue have failed to identify an advantage of PPIs over H₂RAs such as famotidine.^8,9 On the basis of the information available to date, including what we report, we stand by our conclusion that PPIs, as a general rule, offer no advantage over H₂RAs, and that the choice of agent should be based on considerations specific to the situation and the institution.

David R. Gerber, DO, Kizito Ojiako, MD, Hiren Shingala, MD and Christa Schorr, RN, BSN
Camden, New Jersey

REFERENCES

1. Ojiako K, Shingala H, Schorr C, Gerber DR. Famotidine versus pantoprazole for preventing bleeding in the upper gastrointestinal tract of critically ill patients receiving mechanical ventilation. Am J Crit Care. 2008;17(2):142–147.[Abstract/Free Full Text]
2. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994;330(6):377–381.[Abstract/Free Full Text]
3. Faisy C, Guerot E, Diehl J, Iftimovici E, Fagon J. Clinically significant gastrointestinal bleeding in critically ill patients with and without stress-ulcer prophylaxis. Intensive Care Med. 2003;29(8):1306–1313.[Medline]
4. Prod’hom G, Leuenberger P, Koerfer J, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer: a randomized controlled trial. Ann Intern Med. 1994;120:653–662.[Abstract/Free Full Text]
5. Watson TD, Stark JE, Vesta KS. Pantoprazole-induced thrombocytopenia. Ann Pharmacother. 2006;40(4):758–761.[Abstract/Free Full Text]
6. Ben-menachem T, Fogel R, Rakesh P, et al. Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit: a randomized, controlled, single-blind study. Ann Intern Med. 1994;121(8):568–575.[Abstract/Free Full Text]
7. Levy MJ, Seelig CB, Robinson NJ, Ranney JE. Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci. 1997;42(6):1255–1259.[Medline]
8. Kantorova H, Svoboda P, Scheer P, et al. Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology. 2004;51(57):757–761.[Medline]
9. Conrad SA, Gabrielli A, Margolis B, et al. Randomized, double-blind comparison of immediate-release omeprazole oral suspension versus intravenous cimetidine for the prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med. 2005;33(4):760–765.[Medline]

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