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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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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. Executive Summary-Society of Critical Care Medicine Guideline and American Society of Health-System Pharmacists for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Crit Care Med 2024; 52:1295-1299. [PMID: 39007570 DOI: 10.1097/ccm.0000000000006329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
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 Medicine, 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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Toews I, Hussain S, Nyirenda JLZ, Willis MA, Kantorová L, Slezáková S, Boltena MT, Victor PJ, Fontes LES, Klugar M, Sadeghirad B, Meerpohl JJ. Pharmacological interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units: a network meta-analysis. BMJ Evid Based Med 2024:bmjebm-2024-112886. [PMID: 38997152 DOI: 10.1136/bmjebm-2024-112886] [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] [Accepted: 06/14/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVES To assess the efficacy and safety of pharmacological interventions for preventing upper gastrointestinal (GI) bleeding in people admitted to intensive care units (ICUs). DESIGN AND SETTING Systematic review and frequentist network meta-analysis using standard methodological procedures as recommended by Cochrane for screening of records, data extraction and analysis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence. PARTICIPANTS Randomised controlled trials involving patients admitted to ICUs for longer than 24 hours were included. SEARCH METHODS The Cochrane Gut Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Latin American and Caribbean Health Science Information database (LILACS) databases were searched from August 2017 to March 2022. The search in MEDLINE was updated in April 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). MAIN OUTCOME MEASURES The primary outcome was the prevention of clinically important upper GI bleeding. RESULTS We included 123 studies with 46 996 participants. Cimetidine (relative risk (RR) 0.56, 95% CI 0.40 to 0.77, moderate certainty), ranitidine (RR 0.54, 95% CI 0.38 to 0.76, moderate certainty), antacids (RR 0.48, 95% CI 0.33 to 0.68, moderate certainty), sucralfate (RR 0.54, 95% CI 0.39 to 0.75, moderate certainty) and a combination of ranitidine and antacids (RR 0.13, 95% CI 0.03 to 0.62, moderate certainty) are likely effective in preventing upper GI bleeding.The effect of any intervention on the prevention of nosocomial pneumonia, all-cause mortality in the ICU or the hospital, duration of the stay in the ICU, duration of intubation and (serious) adverse events remains unclear. CONCLUSIONS Several interventions seem effective in preventing clinically important upper GI bleeding while there is limited evidence for other outcomes. Patient-relevant benefits and harms need to be assessed under consideration of the patients' underlying conditions.
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Affiliation(s)
- Ingrid Toews
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Salman Hussain
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - John L Z Nyirenda
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Lucia Kantorová
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Simona Slezáková
- Cochrane Czech Republic, Czech Republic: a JBI Centre of Excellence, Czech GRADE Network, Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Minyahil Tadesse Boltena
- Ethiopian Evidence Based Health Care Center, Institute of Health, A Joanna Briggs Institute's Center of Excellence, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Peter John Victor
- Medical Intensive Care Unit, Christian Medical College & Hospital, Vellore, India
| | | | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Center of Evidence-Based Education and Arts Therapies: A JBI Affiliated Group, Palacky University Olomouc Faculty of Education, Olomouc, Olomoucký, Czech Republic
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Daou M, Dionne JC, Teng JFT, Taran S, Zytaruk N, Cook D, Wilcox ME. Prophylactic acid suppressants in patients with primary neurologic injury: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2022; 71:154093. [PMID: 35714455 DOI: 10.1016/j.jcrc.2022.154093] [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: 03/23/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE Neurocritical care patients are at risk of stress-induced gastrointestinal ulceration. We performed a systematic review and meta-analysis of stress ulcer prophylaxis (SUP) in critically ill adults admitted with a primary neurologic injury. MATERIALS AND METHODS We included randomized controlled trials (RCTs) comparing SUP with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs) to placebo/no prophylaxis, as well as to each other. The primary outcome was in-ICU gastrointestinal bleeding (GIB). Predefined secondary outcomes were all-cause 30-day mortality, ICU length of stay (LOS), nosocomial pneumonia, and other complications. RESULTS We identified 14 relevant trials enrolling 1036 neurocritical care patients; 11 trials enrolling 930 patients were included in the meta-analysis. H2RAs resulted in a lower incidence of GIB as compared to placebo or no prophylaxis (Risk ratio [RR] 0.42, 95% CI 0.30-0.58; p < 0.001); PPIs with a lower risk of GIB compared to placebo/no prophylaxis (RR 0.37, 95% CI 0.23-0.59; p < 0.001). No significant difference was observed in GIB comparing PPIs with H2RAs (RR 0.53, 95% CI 0.26-1.06; p = 0.07; I2 = 0%). CONCLUSIONS In neurocritical care patients, the overall high or unclear risk of bias of individual trials, the low event rates, and modest sample sizes preclude strong clinical inferences about the utility of SUP.
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Affiliation(s)
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer F T Teng
- Department of Pharmacy, University Health Network, Toronto, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine (Respirology), University Health Network, Toronto, Canada
| | - Nicole Zytaruk
- St. Joseph's HealthCare Hamilton, Hamilton, Ontario, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; St. Joseph's HealthCare Hamilton, Hamilton, Ontario, Canada
| | - M Elizabeth Wilcox
- Toronto Western Hospital, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine (Respirology), University Health Network, Toronto, Canada.
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5
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Deliwala SS, Hamid K, Goyal H, Ponnapalli A, Zayed Y, Bala A, Lakshman H, Malladi S, Jones S, Santana M, Leon B, An MT, Chawla S. Proton Pump Inhibitors Versus Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Meta-analysis and Trial Sequential Analysis. J Clin Gastroenterol 2022; 56:204-217. [PMID: 34049377 DOI: 10.1097/mcg.0000000000001562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS AND BACKGROUND Stress ulcer prophylaxis has been shown to lower gastrointestinal bleeding (GIB) rates. Various agents have been studied, and the optimal strategy continues to be contested. This study evaluates the efficacy between proton pump inhibitors (PPIs) and histamine-2-receptor antagonists. Small sample sizes and methodology flaws limited prior studies. STUDY A systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science, and ClinicalTrials.gov for randomized controlled trials reporting the use of PPI and histamine-2-receptor antagonist reporting rates of GIB and standardized intensive care outcomes. Risk ratios (RR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). A trial sequential analysis was performed to guard against errors. RESULTS A total of 14 randomized controlled trials of 28,526 patients with a mean age of 57.83±17.35 years and 30.82% females. In our pooled analysis, PPI outperformed its comparator (RR: 0.68; 95% CI: 0.57-0.82) in clinically significant GIB. PPI re-demonstrated significant reduction in overt GIB (RR: 0.61; 95% CI: 0.39-0.97). No differences between groups was noted toward all-cause mortality (RR: 1.05; 95% CI: 1.00-1.10) or incidence of pneumonia (RR: 1.11; 95% CI: 0.82-1.51). Duration of stay (SMD: 0.07; 95% CI: -0.04-0.17) and ventilator days (SMD: 0.01; 95% CI: -0.01-0.04) were indifferent between the groups. CONCLUSIONS Among critically ill patients, PPI was associated with reduced clinically significant or overt GIB. No differences in pneumonia were seen with the use of either agent. Trial sequential analysis for clinically significant GIB ruled out the risk for false-positive results, and thereby it is unlikely that future trials will affect our conclusions.
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Affiliation(s)
- Smit S Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint
| | - Kewan Hamid
- Division of Pulmonary and Critical Care, Saint Peters University Hospital, New Brunswick, NJ
| | - Hemant Goyal
- Division of Gastroenterology, The Wright Center of Graduate Medical Education, Scranton, PA
| | - Anoosha Ponnapalli
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint
| | - Yazan Zayed
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida, Gainesville, FL
| | - Areeg Bala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint
| | - Harini Lakshman
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint
| | - Shrikanth Malladi
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint
| | - Shane Jones
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Maria Santana
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Brianna Leon
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Minh T An
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Saurabh Chawla
- Department of Internal Medicine, Division of Gastroenterology, Emory University, Atlanta, GA
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6
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Song MJ, Kim S, Boo D, Park C, Yoo S, Yoon HI, Cho YJ. Comparison of proton pump inhibitors and histamine 2 receptor antagonists for stress ulcer prophylaxis in the intensive care unit. Sci Rep 2021; 11:18467. [PMID: 34531488 PMCID: PMC8446063 DOI: 10.1038/s41598-021-98069-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022] Open
Abstract
Proton pump inhibitors (PPIs), followed by histamine 2 receptor antagonists (H2RAs), are the most commonly used drugs to prevent gastrointestinal bleeding in critically ill patients through stress ulcer prophylaxis. The relative efficacy and drug-related adverse events of PPIs and H2RAs remain unclear. In this retrospective, observational, comparative cohort study, PPIs and H2RAs for stress ulcer prophylaxis in critically ill patients were compared using a common data model. After propensity matching, 935 patients from each treatment group (PPI or H2RA) were selected. The PPI group had a significantly higher 90-day mortality than the H2RA group (relative risk: 1.28; P = 0.01). However, no significant inter-group differences in the risk of clinically important gastrointestinal bleeding were observed. Moreover, there were no significant differences between the groups concerning the risk of pneumonia or Clostridioides difficile infection, which are known potential adverse events related to these drugs. Subgroup analysis of patients with high disease severity were consistent with those of the total propensity score-matched population. These findings do not support the current recommendations, which prefer PPIs for gastrointestinal bleeding prophylaxis in the intensive care unit.
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Affiliation(s)
- Myung Jin Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Seok Kim
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Dachung Boo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Changhyun Park
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sooyoung Yoo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
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7
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Lee TC, Goodwin Wilson M, Lawandi A, McDonald EG. Proton Pump Inhibitors Versus Histamine-2 Receptor Antagonists Likely Increase Mortality in Critical Care: An Updated Meta-Analysis. Am J Med 2021; 134:e184-e188. [PMID: 32931766 DOI: 10.1016/j.amjmed.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is common among the critically ill. Recently, the Proton Pump Inhibitors (PPIs) vs. Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial suggested PPIs might increase mortality. We performed an updated meta-analysis to further inform discussion. METHODS We leveraged 2 recent systematic reviews to identify randomized controlled trials directly comparing PPIs and H-2 Receptor Antagonists (H2RAs) for stress ulcer prophylaxis in critically ill patients and reporting mortality. We extracted mortality data from each study and meta-analyzed them with the PEPTIC trial using a random effects model. RESULTS Of 28,559 total patients, 14,436 (50.5%) were allocated to PPI and 14,123 to H2RAs (49.5%). Compared to H2RAs, the pooled relative risk for mortality was 1.05 (95% confidence interval 1.00-1.10) with an estimated risk difference for mortality of 9 additional deaths per 1000 patients exposed to PPI (95% confidence interval 0-18); heterogeneity was low (I2 = 0%; P = 0.826). CONCLUSIONS Stress ulcer prophylaxis with PPIs likely increases mortality compared to H2RAs. Whether stress ulcer prophylaxis is beneficial in critical care remains open to further study.
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Affiliation(s)
- Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Department of Medicine, Research Institute, McGill University Health Centre, Montréal, Québec, Canada.
| | - Marnie Goodwin Wilson
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Alexander Lawandi
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Md
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Department of Medicine, Research Institute, McGill University Health Centre, Montréal, Québec, Canada
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8
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Wang Y, Ge L, Ye Z, Siemieniuk RA, Reintam Blaser A, Wang X, Perner A, Møller MH, Alhazzani W, Cook D, Guyatt GH. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: an updated systematic review and network meta-analysis of randomized trials. Intensive Care Med 2020; 46:1987-2000. [PMID: 32833040 DOI: 10.1007/s00134-020-06209-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/01/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients. METHODS We searched for randomized controlled trials that examined the efficacy and safety of gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. We performed Bayesian random-effects NMA and conducted analyses using all PEPTIC data as well as a restricted analysis using only PEPTIC data from high compliance centers. We used the GRADE approach to quantify absolute effects and assess the certainty of evidence. RESULTS Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, 95% credible interval 0.93 to 1.14, moderate certainty) and H2RAs (RR 0.98, 0.89 to 1.08, moderate certainty) probably have little or no impact on mortality compared with no prophylaxis. There may be no important difference between PPIs and H2RAs on mortality (RR 1.05, 0.97 to 1.14, low certainty), the 95% credible interval of the complete analysis has not excluded an important increase in mortality with PPIs. Both PPIs (RR 0.46, 0.29 to 0.66) and H2RAs (RR 0.67, 0.48 to 0.94) probably reduce clinically important gastrointestinal bleeding; the magnitude of reduction is probably greater in PPIs than H2RAs (RR 0.69, 0.45 to 0.93), and the difference may be important in higher, but not lower bleeding risk patients. PPIs (RR 1.08, 0.88 to 1.45, low certainty) and H2RAs (RR 1.07, 0.85 to 1.37, low certainty) may have no important impact on pneumonia compared with no prophylaxis. CONCLUSION This updated NMA confirmed that PPIs and H2RAs are most likely to have a similar effect on mortality compared to each other and compared to no prophylaxis; however, the possibility that PPIs may slightly increase mortality cannot be excluded (low certainty evidence). PPIs and H2RAs probably achieve important reductions in clinically important gastrointestinal bleeding; for higher bleeding risk patients, the greater benefit of PPIs over H2RAs may be important. PPIs or H2RAs may not result in important increases in pneumonia but the certainty of evidence is low.
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Xin Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Deborah Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada. .,Department of Medicine, McMaster University, Hamilton, Canada.
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9
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Abstract
Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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Toews I, George AT, Peter JV, Kirubakaran R, Fontes LES, Ezekiel JPB, Meerpohl JJ. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Cochrane Database Syst Rev 2018; 6:CD008687. [PMID: 29862492 PMCID: PMC6513395 DOI: 10.1002/14651858.cd008687.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding. OBJECTIVES To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs. SEARCH METHODS We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. MAIN RESULTS We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence). AUTHORS' CONCLUSIONS This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.
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Affiliation(s)
- Ingrid Toews
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
| | - Aneesh Thomas George
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - John V Peter
- Christian Medical College & HospitalMedical Intensive Care UnitIda Scudder RoadVelloreTamil NaduIndia632004
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Luís Eduardo S Fontes
- Petrópolis Medical SchoolDepartment of Evidence‐Based Medicine, Intensive Care, GastroenterologyAv Barao do Rio Branco, 1003PetrópolisRJBrazil25680‐120
| | - Jabez Paul Barnabas Ezekiel
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Joerg J Meerpohl
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
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Sridharan K, Sivaramakrishnan G, Gnanaraj J. Pharmacological interventions for stress ulcer prophylaxis in critically ill patients: a mixed treatment comparison network meta-analysis and a recursive cumulative meta-analysis. Expert Opin Pharmacother 2017; 19:151-158. [DOI: 10.1080/14656566.2017.1419187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- Prosthodontics, School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Jerome Gnanaraj
- Department of Medicine, Johns Hopkins Bayview Medical Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Alhazzani W, Alshamsi F, Belley-Cote E, Heels-Ansdell D, Brignardello-Petersen R, Alquraini M, Perner A, Møller MH, Krag M, Almenawer S, Rochwerg B, Dionne J, Jaeschke R, Alshahrani M, Deane A, Perri D, Thebane L, Al-Omari A, Finfer S, Cook D, Guyatt G. Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials. Intensive Care Med 2017; 44:1-11. [PMID: 29199388 PMCID: PMC5770505 DOI: 10.1007/s00134-017-5005-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/24/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers. RESULTS Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies. CONCLUSIONS Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.
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Affiliation(s)
- Waleed Alhazzani
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Mustafa Alquraini
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mette Krag
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Saleh Almenawer
- Department of Surgery, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Joanna Dionne
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Roman Jaeschke
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Adam Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Dan Perri
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada
| | - Lehana Thebane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Awad Al-Omari
- Department of Critical Care, Security Forces Hospital, Riyadh, Saudi Arabia.,Department of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Simon Finfer
- The George Institute for Global Health and Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Deborah Cook
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Division of Critical Care, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, ON, L8N 4A6, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Alshamsi F, Belley-Cote E, Cook D, Almenawer SA, Alqahtani Z, Perri D, Thabane L, Al-Omari A, Lewis K, Guyatt G, Alhazzani W. Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care 2016; 20:120. [PMID: 27142116 PMCID: PMC4855320 DOI: 10.1186/s13054-016-1305-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The relative efficacy and safety of proton pump inhibitors (PPIs) compared to histamine-2-receptor antagonists (H2RAs) should guide their use in reducing bleeding risk in the critically ill. METHODS We searched the Cochrane library, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through November 2015 without language or publication date restrictions. Only randomized controlled trials (RCTs) of PPIs vs H2RAs for stress ulcer prophylaxis in critically ill adults for clinically important bleeding, overt gastrointestinal (GI) bleeding, nosocomial pneumonia, mortality, ICU length of stay and Clostridium difficile infection were included. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the evidence for each outcome. RESULTS In 19 trials enrolling 2117 patients, PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding (RR 0.39; 95 % CI 0.21, 0.71; P = 0.002; I (2) = 0 %, moderate confidence) and overt GI bleeding (RR 0.48; 95 % CI 0.34, 0.66; P < 0.0001; I (2) = 3 %, moderate confidence). PPI use did not significantly affect risk of pneumonia (RR 1.12; 95 % CI 0.86, 1.46; P = 0.39; I (2) = 2 %, low confidence), mortality (RR 1.05; 95 % CI 0.87, 1.27; P = 0.61; I (2) = 0 %, moderate confidence), or ICU length of stay (mean difference (MD), -0.38 days; 95 % CI -1.49, 0.74; P = 0.51; I (2) = 30 %, low confidence). No RCT reported Clostridium difficile infection. CONCLUSIONS PPIs were superior to H2RAs in preventing clinically important and overt GI bleeding, without significantly increasing the risk of pneumonia or mortality. Their impact on Clostridium difficile infection is yet to be determined.
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Affiliation(s)
- Fayez Alshamsi
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Internal Medicine, United Arab Emirates University, Alain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Saleh A Almenawer
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Canada
| | - Zuhoor Alqahtani
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Dan Perri
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Awad Al-Omari
- Department of Critical Care, Security Forces Hospital, Riyadh, Saudi Arabia
- Department of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Kim Lewis
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada.
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada.
- Department of Medicine, Division of Critical Care, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
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Kuo FC, Wu DC. Stress ulcer prophylaxis in the intensive care unit. ADVANCES IN DIGESTIVE MEDICINE 2014. [DOI: 10.1016/j.aidm.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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