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Blankenship CR, Betthauser KD, Hencken LN, Maamari JA, Goetz J, Giacomino BD, Gibson GA. Clinical Response to Third-Line Angiotensin-II vs Epinephrine in Septic Shock: A Propensity-Matched Cohort Study. Ann Pharmacother 2024; 58:1003-1012. [PMID: 38303571 DOI: 10.1177/10600280231226132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The appropriate third-line vasopressor in septic shock patients receiving norepinephrine and vasopressin is unknown. Angiotensin-II (AT-II) offers a unique mechanism of action to traditionally used vasopressors in septic shock. OBJECTIVE The objective of this study was to compare the clinical efficacy and safety of third-line AT-II to epinephrine in patients with septic shock. METHODS A single-center, retrospective cohort study of critically ill patients was performed between April 1, 2019 and July 31, 2022. Propensity-matched (2:1) analysis compared adults with septic shock who received third-line AT-II to controls who received epinephrine following norepinephrine and vasopressin. The primary outcome was clinical response 24 hours after third-line vasopressor initiation. Additional efficacy and safety outcomes were investigated. RESULTS Twenty-three AT-II patients were compared with 46 epinephrine patients. 47.8% of AT-II patients observed a clinical response at hour 24 compared with 28.3% of epinephrine patients (P = 0.12). In-hospital mortality (65.2% vs 73.9%, P = 0.45), cardiac arrhythmias (26.1% vs 26.1%, P = 0.21), and thromboembolism (4.3% vs 2.2%, P = 0.61) were not observed to be statistically different between groups. CONCLUSIONS AND RELEVANCE Administration of AT-II as a third-line vasopressor agent in septic shock patients was not associated with significantly improved clinical response at hour 24 compared with epinephrine. Although underpowered to detect meaningful differences, the clinical observations of this study warrant consideration and further investigation of AT-II as a third-line vasopressor in septic shock.
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Affiliation(s)
| | - Kevin D Betthauser
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Laura N Hencken
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Julie A Maamari
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Jenna Goetz
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Bria D Giacomino
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Gabrielle A Gibson
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
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Chen L, Wang Y. Survival analysis of famotidine administration routes in non-traumatic intracerebral hemorrhage patients: based on the MIMIC-IV database. Expert Rev Pharmacoecon Outcomes Res 2024. [PMID: 39155563 DOI: 10.1080/14737167.2024.2394113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/20/2024]
Abstract
OBJECTIVE This project aims to compare the survival outcomes of non-traumatic intracerebral hemorrhage (ICH) patients with different famotidine administration routes, and explore the risk factors influencing patients' clinical outcomes. METHODS Data of patients admitted to the ICU from 2008 to 2019 and receiving famotidine therapy were collected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients selected for ICU admission > 1 day and treated with famotidine were divided into the group via intravenous (IV) dosing and the group via non-intravenous (Non-IV) dosing. Cox analysis and bilateral stepwise regression were utilized to determine independent prognostic factors affecting patient survival. Survival of patients on different routes of administration before and after propensity score matching (PSM) was compared using Kaplan - Meier (K-M) survival curves. RESULTS This investigation included 351 patients. After PSM was matched with a 1:2 ratio, 109 patients were clustered in the IV group and 84 patients in the Non-IV group. Cox multivariate results uncovered that survival prognosis in ICH patients receiving famotidine was associated with age (HR = 1.031, 95%CI:1.011-1.050, p = 0.002), chloride ion levels (HR = 1.061, 95%CI:1.027-1.096, p < 0.001), blood urea nitrogen (BUN) (HR = 1.034, 95%CI:1.007-1.062, p = 0.012), intracranial pressure (ICP) (HR = 1.059, 95%CI:1.027-1.092, p < 0.001), red blood cell distribution width (RDW) (HR = 1.156, 95%CI:1.030-1.299, p = 0.014), mechanical ventilation (HR = 2.526, 95%CI:1.341-4.760, p = 0.004), antibiotic use (HR = 0.331, 95%CI:0.144-0.759, p = 0.009), and Non-IV route (HR = 0.518, 95%CI:0.283-0.948, p = 0.033). The K-M curve results indicated that the 30-day survival rate of Non-IV group ICH patients was substantially higher than that of IV group patients (before PSM, p = 0.036; after PSM, p = 0.011). In the subgroup analysis of age, ICP, mechanical ventilation, and antibiotic use, there was a great heterogeneity interaction between the administration of famotidine and the 30-day mortality rate (P for interaction < 0.05). The Non-IV route considerably reduced the risk of death in patients with normal ICP (7-15 mmHg) (HR = 0.518, 95%CI:0.283-0.948, p = 0.033). CONCLUSION Among ICH patients receiving famotidine, those receiving famotidine via Non-IV have a better 30-day survival rate compared to those receiving IV, especially in patients with normal ICP (7-15 mmHg).
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Affiliation(s)
- Ling Chen
- Department of Gynaecology, People's Hospital Affiliated to Cangzhou Medical College, Cangzhou, China
| | - Yan Wang
- Department of Basic Medicine, Cangzhou Medical College, Cangzhou, China
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MacLaren R, Dionne JC, Granholm A, Alhazzani W, Szumita PM, Olsen K, Barletta JF, Møller MH, Karvellas CJ, Wischmeyer P, DePriest A, Carlos V, Argetsinger D, Carothers JJ, Lee R, Napolitano L, Perri D, Naylor DF. Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med 2024; 52:e421-e430. [PMID: 39007578 DOI: 10.1097/ccm.0000000000006330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
RATIONALE Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Joanna C Dionne
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Paul M Szumita
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Keith Olsen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Morten Hylander Møller
- Department of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University Medical Center, Durham, NC
| | - Ashley DePriest
- Department of Food and Nutrition, Emory Healthcare, Atlanta, GA
| | | | | | - John J Carothers
- Department of Inpatient Pharmacy, United States Public Health Service, Alaska Native Medical Center, Anchorage, AK
| | - Rosemary Lee
- Critical Care and Progressive Care Units, Baptist Health South Florida, Miami, FL
| | - Lena Napolitano
- Acute Care Surgery, Surgical Critical Care, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Dan Perri
- Division of Gastroenterology and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Divisions of Clinical Pharmacology & Toxicology and Critical Care Medicine, Department of Medicine, McMaster University, Hamiton, ON, Canada
| | - Douglas F Naylor
- Department of Surgery-Trauma Surgery, Critical Care, and Acute Care Surgery, University Hospitals of Cleveland, Cleveland, OH
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Wang Y, Parpia S, Ge L, Heels-Ansdell D, Lai H, Esfahani MA, Pan B, Alhazzani W, Schandelmaier S, Lauzier F, Arabi Y, Barletta J, Deane A, Finfer S, Williamson D, Kanji S, Møller MH, Perner A, Krag M, Young PJ, Dionne JC, Hammond N, Ye Z, Ibrahim Q, Cook D. Proton-Pump Inhibitors to Prevent Gastrointestinal Bleeding - An Updated Meta-Analysis. NEJM EVIDENCE 2024; 3:EVIDoa2400134. [PMID: 38874580 DOI: 10.1056/evidoa2400134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND The goal of this systematic review was to examine the efficacy and safety of proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. METHODS We included randomized trials comparing proton-pump inhibitors versus placebo or no prophylaxis in critically ill adults, performed meta-analyses, and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. To explore the effect of proton-pump inhibitors on mortality based on disease severity, a subgroup analysis was conducted combining within-trial subgroup data from the two largest trials and assessed credibility using the Instrument for Assessing the Credibility of Effect Modification Analyses. RESULTS Twelve trials that enrolled 9533 patients were included. Proton-pump inhibitors were associated with a reduced incidence of clinically important upper gastrointestinal bleeding (relative risk [RR], 0.51 [95% confidence interval (CI), 0.34 to 0.76]; high certainty evidence). Proton-pump inhibitors may have little or no effect on mortality (RR, 0.99 [95% CI, 0.93 to 1.05]; low certainty). Within-trial subgroup analysis with intermediate credibility suggested that the effect of proton-pump inhibitors on mortality may differ based on disease severity. Subgroup results raise the possibility that proton-pump inhibitors may decrease 90-day mortality in less severely ill patients (RR, 0.89; 95% CI, 0.80 to 0.98) and may increase mortality in more severely ill patients (RR, 1.08; 95% CI, 0.96 to 1.20]. Proton-pump inhibitors may have no effect on pneumonia and little or no effect on Clostridioides difficile infection (low certainty). CONCLUSIONS High certainty evidence supports the association of proton-pump inhibitors with decreased upper gastrointestinal bleeding. Proton-pump inhibitors may have little or no effect on mortality, although a decrease in mortality in less severely ill patients and an increase in mortality in more severely ill patients remain possible. (PROSPERO number CRD42023461695.).
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Long Ge
- Evidence-based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Honghao Lai
- Evidence-based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Meisam Abdar Esfahani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Bei Pan
- Center of Evidence-Based Medicine, School of Basic Medical Science, Lanzhou University, Lanzhou, China
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Stefan Schandelmaier
- Division of Clinical Epidemiology, University Hospital and University of Basel, Basel, Switzerland
- School of Public Health, University College Cork, Cork, Ireland
- MTA-PTE Lendület "Momentum" Evidence in Medicine Research Group, Medical School, University of Pécs, Pécs, Hungary
| | - Francois Lauzier
- Population Health and Optimal Health Practice Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, Québec City, QC, Canada
- Department of Medicine, Department of Anesthesiology and Critical Care, Université Laval, Québec, QC, Canada
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jeffrey Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ
| | - Adam Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Simon Finfer
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- School of Public Health, Imperial College London, London, UK
| | - David Williamson
- Pharmacy Department, Université de Montréal, Montréal, QC, Canada
- Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, QC, Canada
| | - Salmaan Kanji
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mette Krag
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Joanna C Dionne
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Divisions of Critical Care Medicine and Gastroenterology, McMaster University, Hamilton, ON, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and UNSW Sydney, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Chen Z, Lin W, Zhang F, Cao W. Risk Factors and Prognosis Analysis of Upper Gastrointestinal Bleeding in Patients With Acute Severe Cerebral Stroke. J Clin Gastroenterol 2024; 58:440-446. [PMID: 37341702 PMCID: PMC10994183 DOI: 10.1097/mcg.0000000000001877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/22/2023] [Indexed: 06/22/2023]
Abstract
GOALS We aim to explore the relationship between the use of proton pump inhibitors (PPIs) and upper gastrointestinal bleeding (UGIB). We develop a nomogram model to predict mortality in critically ill stroke patients. STUDY This is a retrospective study based on the MIMIC IV database. We extracted clinical information including demographic data, comorbidities, and laboratory indicators. Univariate and multivariable logistic regressions were used to assess and identify risk factors for the occurrence of UGIB and for the in-hospital mortality of critically ill stroke patients. The resulting model was used to construct a nomogram for predicting in-hospital mortality. RESULTS Five thousand seven hundred sixteen patients from the MIMIC-IV database were included in our analysis. UGIB occurred in 109 patients (1.9%), whereas the PPI use rate was as high as 60.6%. Chronic liver disease, sepsis, shock, anemia, and increased level of urea nitrogen were independent risk factors for the occurrence of UGIB in severe stroke patients. We identified age, heart failure, shock, coagulopathy, mechanical ventilation, continuous renal replacement therapy, antiplatelet drugs, anticoagulation, simplified acute physiology score-II, and Glasgow coma score as independent risk factors for in-hospital mortality in severe stroke patients. The C-index for the final nomograms was 0.852 (95% confidence interval: 0.840, 0.864). CONCLUSIONS We found that the overall rate of UGIB in severe stroke patients is low, whereas the rate of PPI usage is high. In our study, PPI was not identified as a risk factor for the occurrence of UGIB and UGIB was not associated with all-cause mortality. More clinical trials are needed to evaluate the benefits of using PPI in critically ill stroke patients.
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Cheng J, Cai LY, Tang QQ. Pathogenic mechanism and preventive and therapeutic strategies for secondary stress ulcers in patients with moderate to severe traumatic brain injury. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:97-101. [DOI: 10.11569/wcjd.v32.i2.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
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Sato J, Tanaka R. Effects of Opioids, Steroids, Benzodiazepines, Anticholinergics, and Antihistamines on the Efficacy of Antipsychotics for Treating Delirium in End-of-Life Adult Patients Undergoing Palliative Care. J Pain Palliat Care Pharmacother 2023; 37:298-307. [PMID: 37702451 DOI: 10.1080/15360288.2023.2253241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023]
Abstract
The purpose of the study was to determine the effect of combination therapy involving opioids, steroids, benzodiazepines, anticholinergics, and antihistamines on antipsychotics efficacy for delirium. The study included adult inpatients receiving end-of-life palliative care and diagnosed with hyperactive delirium. Changes in delirium symptoms were assessed using the Intensive Care Delirium Screening Checklist (ICDSC). A retrospective analysis was conducted on 97 patients with ICDSC scores of ≥4, comparing the scores before and after antipsychotic administration. A mean score <4 sustained for 3 days after antipsychotics administration was considered effective. The mean days with ICDSC <4 within a 3-day period were evaluated as well. The efficacy of antipsychotics was compared between cases with and without the use of opioids, steroids, benzodiazepines, anticholinergics, and antihistamines. The results revealed no significant differences in the efficacy of antipsychotics for delirium when used in conjunction with opioids (odds ratio 0.614, 95% CI [0.179-2.105]), benzodiazepines (0.387, [0.108-1.390]), steroids (1.258, [0.276-5.746]), or anticholinergics (2.085, [0. 148-29.458]). Additionally, no significant differences were observed in the mean days with ICDSC <4 within 3-day period. Although opioids, benzodiazepines, steroids, anticholinergics, and antihistamines are recognized as delirium risk factors, their use for symptom relief in patients with delirium may not affect antipsychotic efficacy.
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Affiliation(s)
- Junya Sato
- Department of Pharmacy, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi Prefecture, Japan
- School of Pharmacy, International University of Health and Welfare, Ohtawara City, Tochigi Prefecture, Japan
| | - Rei Tanaka
- Department of Pharmacy, Shizuoka Cancer Center, Sunto-gun, Shizuoka Prefecture, Japan
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda City, Chiba Prefecture, Japan
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Reynolds PM, Wells L, Powell M, MacLaren R. Associated Mortality Risk of Proton Pump Inhibitor Therapy for the Prevention of Stress Ulceration in Intensive Care Unit Patients: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023; 57:586-594. [PMID: 35648972 DOI: 10.1097/mcg.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/27/2022] [Indexed: 12/10/2022]
Abstract
GOALS The aim was to systematically evaluate risks and benefits of proton pump inhibitor (PPI) use for stress ulcer prophylaxis in the critically ill patient. BACKGROUND Whether PPIs increase mortality in the critically ill patient remains controversial. STUDY Systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies with trial sequential analysis, Bayesian sensitivity analysis, and fragility index analysis. RESULTS A total of 31 studies in 78,009 critically ill adults receiving PPIs versus any comparator were included. PPI use was associated with an increased mortality risk in all studies [19.6% PPI vs. 17.5% comparator; RR: 1.10; 95% confidence interval (CI): 1.02-1.20; P =0.01], in the subgroup of RCTs (19.4% vs. 18.7%; RR: 1.05; 95% CI: 1.0-1.09, P =0.04), but not cohort studies (19.9% vs. 16.7%; RR: 1.12; 95% CI: 0.98-1.28, P =0.09). Results were maintained with a Bayesian sensitivity analysis (RR: 1.13; 95% credible interval: 1.035-1.227) and a fragility index analysis, but not sequential analysis ( P =0.16). RCTs with a higher baseline severity of illness revealed the greatest mortality risk with PPI use (32.1% PPI vs. 29.4% comparator; RR: 1.09; 95% CI: 1.04-1.14; P <0.001). PPI use reduced clinically important bleeding in RCTs (1.4% PPI vs. 2.1% comparator; RR: 0.67; 95% CI: 0.5-0.9; P =0.009) but increased bleeding in cohort studies (2.7% PPI vs. 1.2% comparator; RR: 2.05; 95% CI: 1.2-3.52; P =0.009). PPI use was not associated with a lower incidence of clinically important bleeding when compared with histamine-2 receptor antagonists (1.3% vs. 1.9%; RR: 0.59; 95% CI: 0.28-1.25, P =0.09). CONCLUSIONS This meta-analysis demonstrated an association between PPI use and an increased risk of mortality.
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Affiliation(s)
- Paul M Reynolds
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO
| | - Lauren Wells
- PGY2 Emergency Medicine Pharmacy Resident, Froedtert and the Medical College of Wisconsin, Wauwatosa, WI
| | | | - Robert MacLaren
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, CO
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Barletta JF. Prophylactic acid suppression and enteral nutrition. Curr Opin Clin Nutr Metab Care 2023; 26:174-178. [PMID: 36892963 DOI: 10.1097/mco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients who are at high-risk for clinically important gastrointestinal bleeding. Recent evidence however has highlighted adverse effects with acid suppressive therapy, particularly proton pump inhibitors where associations with higher mortality have been reported. Enteral nutrition may provide benefits in reducing the incidence of stress ulceration and may mitigate the need for acid suppressive therapy. This manuscript will describe the most recent evidence evaluating enteral nutrition for the provision of SUP. RECENT FINDINGS There are limited data evaluating enteral nutrition for SUP. The available studies compare enteral nutrition with or without acid suppressive therapy rather than enteral nutrition vs. placebo. Although data exist demonstrating similar clinically important bleeding rates in patients on enteral nutrition who receive SUP vs. no SUP, these studies are underpowered for this endpoint. In the largest placebo-controlled trial conducted to date, lower bleeding rates were observed with SUP and most patients were receiving enteral nutrition. Pooled analyses had also described benefit with SUP vs. placebo and enteral nutrition did not change the impact of these therapies. SUMMARY Although enteral nutrition may provide some benefit as SUP, existing data are not strong enough to validate their use in place of acid suppressive therapy. Clinicians should continue to prescribe acid suppressive therapy for SUP in critically ill patients who are at high risk for clinically important bleeding even when enteral nutrition is being provided.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University, College of Pharmacy - Glendale Campus, Glendale, Arizona, USA
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10
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Effects of anti-ulcer drugs on delirium in trauma patients. Gen Hosp Psychiatry 2023; 80:43-47. [PMID: 36587448 DOI: 10.1016/j.genhosppsych.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Histamine-2 receptor antagonists (H2RAs) may induce a higher risk of developing delirium than proton pump inhibitors (PPIs), but current evidence is insufficient. Therefore, this study aimed to investigate whether anti-ulcer drugs increase delirium risk. METHOD Data were obtained from the medical records of patients admitted to a hospital due to trauma. We compared the incidence of delirium in patients who received H2RAs and PPIs with that in patients who received no anti-ulcer drugs. RESULTS A total of 150, 158, and 238 patients received H2RAs, PPIs, and no anti-ulcer drugs, respectively. Delirium incidence was significantly higher in patients who received H2RAs (34.0%) and PPIs (44.9%) than in those who did not receive anti-ulcer drugs (22.3%). Even after adjustment for possible confounding factors, the association between H2RAs and delirium remained (adjusted OR 1.78; 95% CI 1.04-3.05), but that between PPIs and delirium was attenuated (adjusted OR 1.25; 95% CI 0.71-2.23). CONCLUSIONS Our results show that H2RAs are associated with delirium risk. We replicated findings of a previous data-driven study. Clinicians need to consider the effect of delirium in anti-ulcer drug selection.
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He N, Yan Y, Su S, Ge Q, Zhai S. Are Proton Pump Inhibitors More Effective Than Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients? A Systematic Review and Meta-Analysis of Cohort Studies. Ann Pharmacother 2021; 56:988-997. [PMID: 34971320 DOI: 10.1177/10600280211059040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Histamine-2-receptor antagonists (H2RAs) have been largely replaced by proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) despite the inconclusive evidence concerning comparative effectiveness. OBJECTIVE To compare the effectiveness of PPIs and H2RAs on SUP in real-world setting. METHODS PubMed, Embase, and the Cochrane Library were searched from inception to September 19, 2021. We included cohort studies comparing PPIs with H2RAs in critically ill adult patients and explicitly reporting the outcome of gastrointestinal (GI) bleeding or mortality. Newcastle-Ottawa Scale was used to assess potential risk of bias. We conducted a random-effects meta-analysis and only the studies with adjusted effect estimates were pooled. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the overall quality of the evidence. RESULTS Thirteen cohort studies (N = 145 149) were eligible and 11 of them available for full texts were of low to moderate risk of bias. Meta-analysis of adjusted effect estimates indicated that PPIs were associated with a significantly higher risk of GI bleeding, compared with H2RAs (8 studies, odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.30-3.01, low certainty). Post hoc pooling analysis also suggested that PPIs were associated with a slightly higher risk of mortality in comparison with H2RAs (7 studies, OR = 1.27, 95% CI = 1.13-1.42, low certainty). CONCLUSION AND RELEVANCE The systematic review of cohort studies showed that PPIs were associated with higher risks of GI bleeding and mortality, although the certainty of evidence was low. Overall, we suggest not excluding H2RAs for SUP, while further studies are essential for elucidating the risk stratification, optimal regimen, and specific duration.
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Affiliation(s)
- Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yingying Yan
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Shan Su
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Qinggang Ge
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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