Marks SL, Kook PH, Papich MG, Tolbert MK, Willard MD. ACVIM consensus statement: Support for rational administration of gastrointestinal protectants to dogs and cats. J Vet Intern Med. 2018 Nov;32(6):1823-1840. 

Gastroprotectants are some of the most commonly used (and overused) medications in feline medicine. Several classes of gastroprotectants are commonly utilized to reduce gastric acidity, to treat or prevent ulcers, and to manage esophageal disease. Indications for use have varied widely, and it is often unclear what class of medication is indicated in a given situation, and whether these medications are needed at all. While many gastroprotectants are fairly benign, side effects are common and can include hemolysis, reduced bone density, worsening azotemia, and others (depending on the class of drug). As such, an understanding of the indications for use of given medications in specific scenarios would be of benefit. The American College of Veterinary Internal Medicine (ACVIM) has recently published a consensus statement on the rational administration of gastroprotectants. While the consensus covers both dogs and cats, this summary will discuss cats specifically.

The recommendations were assembled by a panel of experts after extensive review of both the human and veterinary literature. Recommendations are based on peer-reviewed studies and represent the best evidence based medicine available at the time.

The consensus statement first discusses various classes of gastroprotectants. The authors discuss the method of action of these drugs as well as their doing and administration. These include:

• Antacids (ie aluminum salts, calcium carbonate): Difficult to administer, high dosing frequency needed, impractical for use and superior options available.
• Histamine type 2 receptor antagonists (ie famotidine, ranitidine): No benefit to once daily use. Twice daily use is inferior to a proton pump inhibitor (PPI). No benefit to combining an H2 Antagonist with a PPI
• Proton pump inhibitors: The most effective option to decrease gastric acidity. Should be dosed twice daily. Should be tapered after prolonged use. No evidence that one is superior to another.
• Misoprostol: No evidence for use as an ulcer preventative. May decrease ulcer formation with aspirin, unsure about other NSAIDs
• Sucralfate: Weak evidence for use in esophageal injury. No benefit to combining with a PPI or H2RA, and PPIs are superior in treating ulceration.

After a discussion of these types of gastroprotectant, the panel discusses specific indications for gastroprotection. Each of these includes and in depth discussion of the reasoning behind these choices. The recommendations include:

• Gastroduodenal erosion and ulceration: PPIs twice daily as a sole agent should be the standard of care for animals with documented or strongly suspected gastroduodenal erosion and ulceration
• Gastritis: No evidence for the use of any therapy as a prophylactic in animals with non erosive gastritis
• Hepatic disease: Weak evidence to support the use of prophylactic gastroprotectants in animals with hepatic disease not associated with bleeding.
• Stress-related mucosal damage: No compelling evidence for antacid therapy in critically ill patients unless GI hemorrhage or NSAID therapy are present.
• Renal disease: No evidence for acid suppressant therapy in animals with IRIS 1-3 CKD. More data is needed for animals in IRIS stage 4.
• Pancreatitis: No evidence for the use of acid suppression unless erosion or ulceration is present.
• Reflux esophagitis: The use of PPIs is likely indicated, especially when associated with an anesthetic procedure.
• Helicobacter: No evidence for acid suppression in non-helicobacter pylori helicobacter infections, which is almost always the case in feline medicine.

In consensus, the panel’s recommendations generally trend towards a preference for PPIs over other classes of drugs, and limiting the use of gastroprotectants to those situations where there is direct or highly suspected evidence of erosion or ulceration of the gastric mucosa. Future directions for research include more controlled studies on these medications, their long and short-term efficacy and side effects, and the approval of label claims of some of these medications for veterinary species. (MRK)

See Also

1. Rakesh TP. Proton pump inhibitors: use, misuse and concerns about long-term therapy. Clin J Gastroenterol. 2011;4:53-59.
2. Gould E, Clements C, Reed A, et al. A prospective, placebo-controlled pilot evaluation of the effect of omeprazole on serum calcium, magnesium, cobalamin, gastrin concentrations, and bone in cats. J Vet Intern Med. 2016;30:779-786
3. Parkinson S, Tolbert K, Messenger K, et al. Evaluation of the effect of orally administered acid suppressants on intragastric pH in cats. J Vet Intern Med. 2015;29:104-112.