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Li F, Liu H, Zhang L, Huang X, Liu Y, Li B, Xu C, Lyu J, Yin H. Effects of Gastric Acid Secretion Inhibitors for Ventilator-Associated Pneumonia. Front Pharmacol 2022; 13:898422. [PMID: 35600874 PMCID: PMC9117634 DOI: 10.3389/fphar.2022.898422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: This study analyzed the association of gastric acid secretion inhibitors (GASIs) [including proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs)] with the occurrence of ventilator-associated pneumonia (VAP) and in-hospital mortality in patients who received invasive mechanical ventilation (IMV). Method: Patients who received IMV and used GASI were included based on records in the MIMIC-IV database. The relationships of GASIs with VAP and the in-hospital mortality were determined using univariate and multivariate logistic regression analyses. Also, the effects of GASIs in some subgroups of the population were further analyzed. Results: A total of 18,669 patients were enrolled, including 9191 patients on H2RAs only, 6921 patients on PPIs only, and 2557 were on a combination of the two drugs. Applying logistic regression to the univariate and multivariate models revealed that compared with H2RAs, PPIs had no significant effect on the incidence of VAP, and the combination of H2RAs and PPIs was a risk factor for VAP. Compared with H2RAs, univariate logistic regression revealed that, PPIs and combine the two drugs were both risk factors for in-hospital mortality, but multivariate logistic regression showed that they were not significantly associated with in-hospital mortality. In subgroup analysis, there were interaction in different subgroups of age, PCO2, myocardial infarct, congestive heart failure (P for interaction<0.05). Conclusion: Compared with H2RAs, PPIs did not have a significant association with either VAP or in-hospital mortality; the combination of H2RAs and PPIs was risk factor for VAP, but did not have a significantly associated with in-hospital mortality.
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Affiliation(s)
- Fang Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangdong, China
- Department of Intensive Care Unit, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Hui Liu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangdong, China
| | - Luming Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangdong, China
| | - Xiaxuan Huang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangdong, China
| | - Yu Liu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangdong, China
| | - Boen Li
- Department of Intensive Care Unit, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Chao Xu
- Department of Intensive Care Unit, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangdong, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangdong, China
- *Correspondence: Jun Lyu, ; Haiyan Yin,
| | - Haiyan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangdong, China
- *Correspondence: Jun Lyu, ; Haiyan Yin,
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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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Almadi MA, Gardner TB, Chen YI, Adam V, Barkun J, Barkun A. Use of stents in patients undergoing chemotherapy for borderline resectable pancreatic cancer-causing biliary obstruction while awaiting surgery: A cost-effectiveness analysis. Endosc Int Open 2021; 9:E1413-E1420. [PMID: 34466367 PMCID: PMC8382504 DOI: 10.1055/a-1497-1562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/20/2021] [Indexed: 10/31/2022] Open
Abstract
Background and study aims Biliary stenting is indicated to relieve obstruction from borderline resectable pancreatic cancer while patients receive preoperative neoadjuvant therapy. We compared the cost-effectiveness of plastic versus metal biliary stenting in this setting. Methods A decision tree analysis compares two competing types of biliary stents (initially metal vs. initially plastic) to treat malignant distal biliary obstruction while receiving neoadjuvant therapy with different scenarios including possible complications as bridge till the patient undergoes curative surgical attempt. Using published information, effectiveness was chosen as the probability of successfully reaching a state of being ready for surgery once chemotherapy was completed. Costs (2018 US$) were based on national data. A third-party payer perspective was adopted, and sensitivity analyses were performed over a time-horizon of one year. Results Initially inserting a metal versus a plastic biliary stent was more efficacious with a higher probability of reaching the readiness for surgery endpoint (96 % vs. 85 %), on average 18 days earlier while also being less expensive (US$ 9,304 vs. US$ 11,538). Sensitivity analyses confirmed robustness of these results across varying probability assumptions of plausible ranges and remained a dominant strategy even when lowering the willingness-to-pay threshold to US$ 1,000. Conclusions Initial metal stenting to relieve malignant biliary obstruction from borderline resectable pancreatic cancer in patients undergoing neoadjuvant therapy prior to surgery is a dominant intervention in economic terms, when compared to initially inserting a plastic biliary stent as it results in a greater proportion of patients being fit for surgery earlier and at a lower cost.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Yen-I Chen
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Viviane Adam
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Association of Histamine-2 Blockers and Proton-Pump Inhibitors With Delirium Development in Critically Ill Adults: A Retrospective Cohort Study. Crit Care Explor 2021; 3:e0507. [PMID: 34396144 PMCID: PMC8357254 DOI: 10.1097/cce.0000000000000507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Histamine-2 receptor antagonists are commonly administered for stress ulcer prophylaxis in critically ill adults and may be associated with delirium development. We aimed to determine differential associations of histamine-2 receptor antagonist or proton-pump inhibitor administration with delirium development in patients admitted to a medical ICU. DESIGN: Retrospective observational study using a deidentified database sourced from the University of North Carolina Health Care system. Participants were identified as having delirium utilizing an International Classification of Diseases-based algorithm. Associations among histamine-2 receptor antagonist, proton-pump inhibitor, or no medication administration and delirium were identified using relative risk. Multiple logistic regression was used to control for potential confounders including mechanical ventilation and age. SETTING: Academic tertiary care medical ICU in the United States. PATIENTS: Adults admitted to the University of North Carolina medical ICU from January 2015 to December 2019, excluding those on concurrent histamine-2 receptor antagonists and proton-pump inhibitors in the same encounter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 6,645 critically ill patients, of whom 29% (n = 1,899) received mechanical ventilation, 45% (n = 3,022) were 65 or older, and 22% (n = 1,487) died during their medical ICU encounter. Of the 6,645 patients, 31% (n = 2,057) received an histamine-2 receptor antagonist and no proton-pump inhibitors, 40% (n = 2,648) received a proton-pump inhibitor and no histamine-2 receptor antagonists, and 46% (n = 3,076) had delirium. The histamine-2 receptor antagonist group had a greater association with delirium than the proton-pump inhibitor group compared with controls receiving neither medication, after controlling for mechanical ventilation and age (risk ratio, 1.36; 1.25–1.47; p < 0.001) and (risk ratio, 1.15; 1.07–1.24; p < 0.001, respectively). CONCLUSIONS: Histamine-2 receptor antagonists are more strongly associated with increased delirium than proton-pump inhibitors. Prospective studies are necessary to further elucidate this association and to determine if replacement of histamine-2 receptor antagonists with proton-pump inhibitors in ICUs decreases the burden of delirium in critically ill patients.
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Alrajhi S, Barkun A, Adam V, Callichurn K, Martel M, Brewer O, Khashab MA, Forbes N, Almadi MA, Chen YI. Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective. Therap Adv Gastroenterol 2021; 14:17562848211031388. [PMID: 34804204 PMCID: PMC8600178 DOI: 10.1177/17562848211031388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. METHODS A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. RESULTS The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. CONCLUSIONS Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.
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Affiliation(s)
- Saad Alrajhi
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Viviane Adam
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Kashi Callichurn
- Department of Internal Medicine, University of Montreal, Montreal, QC, Canada
| | - Myriam Martel
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Majid A. Almadi
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, Canada
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Glen Site, 1001 Décarie Blvd., Montreal, QC H4A 3J1, Canada
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6
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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7
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Barkun AN, Adam V, Wong RCK. Use of Doppler Probe in Nonvariceal Upper-Gastrointestinal Bleeding Is Less Costly and More Effective Than Standard of Care. Clin Gastroenterol Hepatol 2019; 17:2463-2470. [PMID: 30772584 DOI: 10.1016/j.cgh.2019.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/28/2019] [Accepted: 02/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Upper gastrointestinal bleeding is a common emergency and rebleeding is associated with an increased risk of death. Proper assessment of high-risk lesions and appropriate endoscopic hemostasis are required for the best outcomes. The endoscopic Doppler probe examination (DPE) allows for a more complete assessment of the stigmata of hemorrhage, providing better evaluation of the need for endoscopic hemostasis and determination of its completeness. We aimed to evaluate whether use of the DPE provides an additional advantage in cost and effectiveness compared with traditional endoscopic visual assessment (TEA) of high-risk stigmata in patients with nonvariceal upper gastrointestinal bleeding. METHODS We drew a decision tree representing the choice between DPE and TEA approaches for patients undergoing an index endoscopy for active nonvariceal upper gastrointestinal bleeding. Clinical probabilities were retrieved from randomized controlled trial data. Costs were expressed in 2017 US dollars. A third-party payer perspective was adopted. We performed deterministic and probabilistic sensitivity analyses. The adopted time horizon was 30 days after the index endoscopy. RESULTS We found that DPE is a dominant strategy over the TEA, in that DPE is more efficacious (92.6% of patients avoiding rebleeding vs 78.6% for TEA) and less expensive ($8502 vs $9104 for TEA). The economic dominance of DPE over TEA was robust to sensitivity analyses across all assumptions of the model when varied among ranges spanning 30% of their respective baseline values. CONCLUSIONS In a cost-effectiveness analysis, we found DPE to be an economically dominant strategy to TEA (the traditional approach) in the management of high-risk lesions in patients with nonvariceal upper gastrointestinal bleeding. DPE was less costly and more effective.
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Affiliation(s)
- Alan N Barkun
- Division of Gastroenterology, Montreal General Hospital, McGill University, Montreal, Canada.
| | - Viviane Adam
- Division of Gastroenterology, Montreal General Hospital, McGill University, Montreal, Canada
| | - Richard C K Wong
- Division of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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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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9
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Barletta JF, Buckley MS, MacLaren R. The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis? Hosp Pharm 2019; 55:96-101. [PMID: 32214442 DOI: 10.1177/0018578719867687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of stress ulcer-induced, clinically important bleeding (CIB). Recently, the value of SUP has been questioned due to the perceived decline in CIB and the potential for infectious complications secondary to acid suppressive therapy. The SUP-ICU trial is a large, randomized controlled trial comparing intravenous pantoprazole with placebo for the indication of SUP. It is hoped that this trial would answer many of the questions pertaining to the overall value of SUP. This article will provide an in-depth assessment of the SUP-ICU trial in the context of the overall body of literature in this area. Furthermore, applications for clinical practice and recommendations on the provision of SUP are provided. Summary: The SUP-ICU trial revealed no difference in the primary outcome of 90-day mortality with pantoprazole but lower rates of CIB were noted (which was a secondary outcome). Overall, these data provide important insight into the value of SUP along with other questions related to the provision of SUP such as the relationship between CIB and mortality, infectious complications, and enteral nutrition. Conclusions: The SUP-ICU trial is a landmark trial describing the value of SUP in a modern-day setting of intensive care unit (ICU) practice. The provision of SUP should be continued in high-risk patients. Future studies are ongoing that will add further insight to this routine practice.
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Mendes JJ, Silva MJ, Miguel LS, Gonçalves MA, Oliveira MJ, Oliveira CDL, Gouveia J. Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit. Rev Bras Ter Intensiva 2019; 31:5-14. [PMID: 30843949 PMCID: PMC6443317 DOI: 10.5935/0103-507x.20190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/08/2018] [Indexed: 12/18/2022] Open
Abstract
Critically ill patients are at risk of developing stress ulcers in the upper
digestive tract. Agents that suppress gastric acid are commonly prescribed to
reduce the incidence of clinically important stress ulcer-related
gastrointestinal bleeding. However, the indiscriminate use of stress ulcer
prophylaxis in all patients admitted to the intensive care unit is not warranted
and can have potential adverse clinical effects and cost implications. The
present guidelines from the Sociedade Portuguesa de Cuidados
Intensivos summarizes the current evidence and gives six clinical
statements and an algorithm aiming to provide a standardized prescribing policy
for the use of stress ulcer prophylaxis in the intensive care unit.
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Affiliation(s)
| | - Mário Jorge Silva
- Departamento de Gastrenterologia, Centro Hospitalar de Lisboa Central E.P.E. - Lisboa, Portugal
| | - Luís Silva Miguel
- Centro de Medicina Baseada em Evidência, Faculdade de Medicina, Universidade de Lisboa - Lisboa, Portugal
| | | | - Maria João Oliveira
- Departamento de Farmácia, Hospital Prof. Doutor Fernando da Fonseca E.P.E. - Amadora, Portugal
| | | | - João Gouveia
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa, Portugal
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Azab M, Doo L, Doo DH, Elmofti Y, Ahmed M, Cadavona JJ, Liu XB, Shafi A, Joo MK, Yoo JW. Comparison of the Hospital-Acquired Clostridium difficile Infection Risk of Using Proton Pump Inhibitors versus Histamine-2 Receptor Antagonists for Prophylaxis and Treatment of Stress Ulcers: A Systematic Review and Meta-Analysis. Gut Liver 2018; 11:781-788. [PMID: 28506028 PMCID: PMC5669593 DOI: 10.5009/gnl16568] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 12/17/2022] Open
Abstract
Background/Aims Although proton pump inhibitors (PPIs) have been widely used for the prevention and treatment of stress gastric ulcers in hospital settings, there are concerns that PPIs increase the risk of Clostridium difficile infection (CDI). However, little is known about the risk of CDI following PPI and histamine-2 receptor antagonist (H2RA) use. We evaluated the comparative hospital-acquired CDI occurrence risk associated with the concurrent use of PPIs versus H2RAs. Methods A systematic search of PubMed, MEDLINE/Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Google Scholar through August 19, 2016, identified 12 studies that reported the hospital-acquired CDI occurrence following H2RA and PPI use for the prevention and treatment of stress gastric ulcers. Random-effects pooled odds ratios and 95% confidence intervals were estimated. Heterogeneity was measured using I², and a meta-regression analysis was conducted. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the overall quality of the evidence. Results A total of 74,132 patients from 12 observational studies were analyzed. Compared to H2RAs, PPIs increased the risk of CDI by 38.6% (pooled odds ratio, 1.386; 95% confidence interval, 1.152 to 1.668; p=0.001; I²=42.81%). Subgroup analyses of the purpose of study medication use, study site, and study design confirmed the consistency of a greater CDI risk with PPIs than with H2RAs. The overall quality of evidence was rated as low. Conclusions The use of PPIs for both the prevention and treatment of stress ulcers was associated with a 38.6% increased risk of hospital-acquired CDI occurrence compared to H2RA use.
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Affiliation(s)
- Mohamed Azab
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - Loomee Doo
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - Daniel H Doo
- Department of Global Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Yousif Elmofti
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - Muazer Ahmed
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV, USA
| | - John Jay Cadavona
- Department of Graduate Education, University of Nevada School of Medicine, Reno, NV, USA
| | - Xibei B Liu
- Department of Graduate Education, University of Nevada School of Medicine, Reno, NV, USA
| | - Amaan Shafi
- Department of Graduate Education, University of Nevada School of Medicine, Reno, NV, USA
| | - Moon Kyung Joo
- Institute of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV, USA
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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: 88] [Impact Index Per Article: 12.6] [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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Hammond DA, Killingsworth CA, Painter JT, Pennick RE, Chatterjee K, Boye B, Meena N. Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults. Pharm Pract (Granada) 2017; 15:948. [PMID: 28943978 PMCID: PMC5597806 DOI: 10.18549/pharmpract.2017.03.948] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
Background: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB). Objective: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST. Methods: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests. Results: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively). Conclusion: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.
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Affiliation(s)
- Drayton A Hammond
- Assistant Professor of Pharmacy Practice. Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | | | - Jacob T Painter
- Assistant Professor of Pharmacy Practice. Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | - Rose E Pennick
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | - Kshitij Chatterjee
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| | - Bradley Boye
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| | - Nikhil Meena
- Assistant Professor of Medicine. Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3697] [Impact Index Per Article: 528.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Hammond DA, Kathe N, Shah A, Martin BC. Cost-Effectiveness of Histamine 2 Receptor Antagonists Versus Proton Pump Inhibitors for Stress Ulcer Prophylaxis in Critically Ill Patients. Pharmacotherapy 2016; 37:43-53. [PMID: 27809338 DOI: 10.1002/phar.1859] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE To determine the cost-effectiveness of stress ulcer prophylaxis with histamine2 receptor antagonists (H2RAs) versus proton pump inhibitors (PPIs) in critically ill and mechanically ventilated adults. DESIGN A decision analytic model estimating the costs and effectiveness of stress ulcer prophylaxis (with H2RAs and PPIs) from a health care institutional perspective. PATIENTS Adult mixed intensive care unit (ICU) population who received an H2RA or PPI for up to 9 days. MEASUREMENTS AND MAIN RESULTS Effectiveness measures were mortality during the ICU stay and complication rate. Costs (2015 U.S. dollars) were combined to include medication regimens and untoward events associated with stress ulcer prophylaxis (pneumonia, Clostridium difficile infection, and stress-related mucosal bleeding). Costs and probabilities for complications and mortality from complications came from randomized controlled trials and observational studies. A base case scenario was developed with pooled data from an observational study and meta-analysis of randomized controlled trials. Scenarios based on observational and meta-analysis data alone were evaluated. Outcomes were expected and incremental costs, mortalities, and complication rates. Univariate sensitivity analyses were conducted to determine the influence of inputs on cost, mortality, and complication rates. Monte Carlo simulations evaluated second-order uncertainty. In the base case scenario, the costs, complication rates, and mortality rates were $9039, 17.6%, and 2.50%, respectively, for H2RAs and $11,249, 22.0%, and 3.34%, respectively, for PPIs, indicating that H2RAs dominated PPIs. The observational study-based model provided similar results; however, in the meta-analysis-based model, H2RAs had a cost of $8364 and mortality rate of 3.2% compared with $7676 and 2.0%, respectively, for PPIs. At a willingness-to-pay threshold of $100,000/death averted, H2RA therapy was superior or preferred 70.3% in the base case and 97.0% in the observational study-based scenario. PPI therapy was preferred 87.2% in the meta-analysis-based scenario. CONCLUSION Providing stress ulcer prophylaxis with H2RA therapy may reduce costs, increase survival, and avoid complications compared with PPI therapy. This finding is highly sensitive to the pneumonia and stress-related mucosal bleeding rates and whether observational data are used to inform the model.
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Affiliation(s)
- Drayton A Hammond
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, Arkansas
| | - Niranjan Kathe
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, Arkansas
| | - Anuj Shah
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, Arkansas
| | - Bradley C Martin
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, Arkansas.,Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, Arkansas
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Rafinazari N, Abbasi S, Farsaei S, Mansourian M, Adibi P. Adherence to stress-related mucosal damage prophylaxis guideline in patients admitted to the Intensive Care Unit. J Res Pharm Pract 2016; 5:186-92. [PMID: 27512710 PMCID: PMC4966238 DOI: 10.4103/2279-042x.185728] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective: Concern about adverse effects of the inconsistent use of stress-related mucosal damage prophylaxis in intensive care unit (ICU) is increasing. Hence, this study was designed to prospectively evaluate the rate of inappropriate stress ulcer prophylaxis (SUP) administration upon ICU admission, at ICU discharge and determine the adherence to American Society of Health-System Pharmacists (ASHP) guideline during ICU stay. Methods: In this study, 200 patients were randomly selected from all ICU admissions during 9 months. Risk factors of stress ulcer were recorded daily during ICU stay and appropriateness of SUP administration was assessed according to the ASHP criteria. Findings: Of all 160 (80%) patients who received SUP, 44.4% did not have indication; and among 95 patients with an indication for SUP administration, 6.3% did not receive it upon ICU admission. Consequently, 77 (38.5%) of 200 patients received inappropriate prophylaxis on ICU admission. In addition, 53.5% of patients had appropriate adherence to ASHP guideline during all days of ICU stay (44% and 2.5% of patients received SUP more than 120% and <80% of appropriate SUP duration, respectively). Moreover, 81.2% were continued on inappropriate prophylaxis upon transfer from the ICU. Conclusion: We concluded that although SUP administration included both overutilization and underutilization in this ICU, but high prevalence of SUP overutilization caused unnecessary hospital costs, personal monetary burden, and may increase adverse drug reactions. Therefore, educating physicians and cooperation of clinical pharmacists regarding implementing standard protocols could improve patterns of SUP administration.
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Affiliation(s)
- Niloofar Rafinazari
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Abbasi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Farsaei
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan Pharmaceutical Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjan Mansourian
- Department of Biostatistics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peyman Adibi
- Department of Gastroenterology, Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Lin CC, Hsu YL, Chung CS, Lee TH. Stress ulcer prophylaxis in patients being weaned from the ventilator in a respiratory care center: A randomized control trial. J Formos Med Assoc 2016; 115:19-24. [DOI: 10.1016/j.jfma.2014.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 02/01/2023] Open
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Barkun AN, Adam V, Martel M, AlNaamani K, Moses PL. Partially covered self-expandable metal stents versus polyethylene stents for malignant biliary obstruction: a cost-effectiveness analysis. Can J Gastroenterol Hepatol 2015; 29:377-83. [PMID: 26125107 PMCID: PMC4610649 DOI: 10.1155/2015/743417] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 03/17/2015] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED BACKGROUND⁄ OBJECTIVE Partially covered self-expandable metal stents (SEMS) and polyethylene stents (PES) are both commonly used in the palliation of malignant biliary obstruction. Although SEMS are significantly more expensive, they are more efficacious than PES. Accordingly, a cost-effectiveness analysis was performed. METHODS A cost-effectiveness analysis compared the approach of initial placement of PES versus SEMS for the study population. Patients with malignant biliary obstruction underwent an endoscopic retrograde cholangiopancreatography to insert the initial stent. If the insertion failed, a percutaneous transhepatic cholangiogram was performed. If stent occlusion occurred, a PES was inserted at repeat endoscopic retrograde cholangiopancreatography, either in an outpatient setting or after admission to hospital if cholangitis was present. A third-party payer perspective was adopted. Effectiveness was expressed as the likelihood of no occlusion over the one-year adopted time horizon. Probabilities were based on a contemporary randomized clinical trial, and costs were issued from national references. Deterministic and probabilistic sensitivity analyses were performed. RESULTS A PES-first strategy was both more expensive and less efficacious than an SEMS-first approach. The mean per-patient costs were US$6,701 for initial SEMS and US$20,671 for initial PES, which were associated with effectiveness probabilities of 65.6% and 13.9%, respectively. Sensitivity analyses confirmed the robustness of these results. CONCLUSION At the time of initial endoscopic drainage for patients with malignant biliary obstruction undergoing palliative stenting, an initial SEMS insertion approach was both more effective and less costly than a PES-first strategy.
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Affiliation(s)
- Alan N Barkun
- Division of Gastroenterology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
- Division of Epidemiology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
| | - Viviane Adam
- Division of Gastroenterology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
| | - Myriam Martel
- Division of Gastroenterology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
| | - Khalid AlNaamani
- Division of Gastroenterology, Hepatology and Liver Transplantation, The Armed Forces Hospital, Muscat, Oman
| | - Peter L Moses
- Division of Gastroenterology and Hepatology, University of Vermont, Burlington, Vermont, USA
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Abstract
AIM: To assess the value of pantoprazole in the prevention of post-traumatic stress ulcer.
METHODS: One hundred and eight patients who underwent major surgery or surgical critical patients treated from January 2012 to January 2014 at Nanyang Central Hospital were randomly divided into either an observation group or a control group, with 54 cases in each group. The observation group was given pantoprazole, and the control group was given cimetidine. After two weeks of therapy, the incidence of stress ulcer and gastric pH were compared for the two groups.
RESULTS: Two cases of stress ulcer developed in the observation group, and the rate was 3.71%. Eleven cases of stress ulcer were observed in the control group, and the rate was 20.38%. The rate of stress ulcer differed significantly between the two (P < 0.05). Preoperative gastric pH values in the observation group and control group were 2.00 ± 0.22 and 2.00 ± 0.23, respectively, and corresponding postoperative values were 2.00 ± 0.23 and 7.20 ± 1.10. Gastric pH values both before and after surgery in the observation group were significantly higher than those in the control group (P < 0.05).
CONCLUSION: Pantoprazole compared with cimetidine is effective in the prevention of traumatic stress ulcer and can significantly reduce the incidence of stress ulcer.
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Bardou M, Quenot JP, Barkun A. Stress-related mucosal disease in the critically ill patient. Nat Rev Gastroenterol Hepatol 2015; 12:98-107. [PMID: 25560847 DOI: 10.1038/nrgastro.2014.235] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.
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Affiliation(s)
- Marc Bardou
- Gastroenterology and Hepatology Department, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, CHU de Dijon, France, 14 Rue Gaffarel BP77908, 21079 Dijon Cedex, France
| | - Alan Barkun
- Gastroenterology Department, McGill University Health Centre, Montreal General Hospital Site, Room D7-346, 1650 Cedar Avenue, Montréal, QC H3G 1A4, Canada
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Kleiman DA, Zarnegar R. An old tool may fix a new problem: early utilization of 24-h esophageal pH monitoring may reduce unnecessary proton-pump inhibitor use and improve outcomes. J Comp Eff Res 2014; 2:409-11. [PMID: 24236735 DOI: 10.2217/cer.13.60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- David A Kleiman
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, Box 207, New York, NY, USA
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MacLaren R, Kassel LE, Kiser TH, Fish DN. Proton pump inhibitors and histamine-2 receptor antagonists in the intensive care setting: focus on therapeutic and adverse events. Expert Opin Drug Saf 2014; 14:269-80. [DOI: 10.1517/14740338.2015.986456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Feng Y, Chen XY, Su MX. Efficacy of lansoprazole combined with conventional treatment in relieving gastrointestinal symptoms in patients with anxiety. Shijie Huaren Xiaohua Zazhi 2014; 22:4012-4016. [DOI: 10.11569/wcjd.v22.i26.4012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the efficacy of lansoprazole combined with conventional treatment in relieving gastrointestinal symptoms in patients with anxiety.
METHODS: One hundred and eighteen anxiety patients with gastrointestinal symptoms treated from January 2011 to March 2014 at our hospital were randomly divided into either a treatment group or a control group, with 59 cases in each groups. The control group was given conventional treatment and symptomatic treatment for gastrointestinal symptoms, and the treatment group was given oral lansoprazole tablets on the basis of the treatments in the control group. Esophageal pH value (EpH), esophageal pressure (LESP), duration of symptoms, number of fecal occult blood positive cases, numbers of cases of postprandial fullness, acid reflux, belching and irregular abdominal pain, and drug adverse reactions were compared between the two groups before and 6 wk after treatment.
RESULTS: There were no statistically significant differences in EpH, LESP, number of fecal occult blood positive cases, or numbers of cases of postprandial fullness, acid reflux, belching and irregular abdominal pain between the two groups before treatment (P > 0.05). The EpH (5.68 ± 1.52 vs 4.98 ± 1.47) and LESP (12.46 mmHg ± 4.29 mmHg vs 9.76 mmHg ± 3.17 mmHg) were significantly higher, and the duration of symptoms, number of fecal occult blood positive cases, numbers of cases of postprandial fullness, acid reflux, belching, and irregular abdominal pain were significantly lower in the treatment group than in the control group 6 wk after treatment (P < 0.05). The numbers of cases of persistent abdominal pain, diarrhea, anemia and vomiting blood or bloody stool were also significantly lower in the treatment group than in the control group (P < 0.05).
CONCLUSION: Lansoprazole combined with conventional treatment can significantly reduce the extent and duration of symptoms and the incidence of gastrointestinal complications in anxiety patients with gastrointestinal symptoms.
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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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Stress ulcer prophylaxis: it's that same old wine in a brand new bottle*. Crit Care Med 2014; 42:979-80. [PMID: 24633095 DOI: 10.1097/ccm.0000000000000065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients*. Crit Care Med 2014; 42:809-15. [PMID: 24365863 DOI: 10.1097/ccm.0000000000000032] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. DESIGN Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data. SETTING A simulation model. PATIENTS A mixed adult ICU population. INTERVENTIONS Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy. MAIN MEASUREMENTS AND RESULTS Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively, resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favorable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favored proton pump inhibitors. CONCLUSIONS Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.
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Kleiman DA, Beninato T, Bosworth BP, Brunaud L, Ciecierega T, Crawford CV, Turner BG, Fahey TJ, Zarnegar R. Early referral for esophageal pH monitoring is more cost-effective than prolonged empiric trials of proton-pump inhibitors for suspected gastroesophageal reflux disease. J Gastrointest Surg 2014; 18:26-33; discussion 33-4. [PMID: 24214090 DOI: 10.1007/s11605-013-2327-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/19/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The most cost-effective diagnostic algorithm for gastroesophageal reflux disease (GERD) remains controversial. We hypothesized that prompt referral for esophageal pH monitoring is more cost-effective than prolonged empiric courses of proton-pump inhibitors (PPIs). DISCUSSION A cost model was created based on a cohort of 100 patients with possible GERD who underwent pH monitoring. The additional costs incurred from pH monitoring were compared to the potential savings from avoiding unnecessary PPI usage in patients with a negative pH study. The costs of PPI therapy reach equivalence with pH monitoring after 6.4 to 23.7 weeks, depending on the PPI regimen. A total of 21,411 weeks of PPIs were prescribed beyond the recommended 8-week trial, of which 32 % were for patients who had a negative 24-h pH monitoring study. If the sensitivity of pH monitoring was 96 %, early referral for pH monitoring would have saved between $1,197 and $6,303 per patient over 10 years. This strategy remains cost-effective as long as the sensitivity of pH monitoring is above 35 %. Prompt referral for pH monitoring after a brief empiric PPI trial is a more cost-effective strategy than prolonged empiric PPI trials for patients with both esophageal and extraesophageal GERD symptoms.
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Affiliation(s)
- David A Kleiman
- Division of Endocrine and Minimally Invasive Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA
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Barletta JF, Sclar DA. Use of proton pump inhibitors for the provision of stress ulcer prophylaxis: clinical and economic consequences. PHARMACOECONOMICS 2014; 32:5-13. [PMID: 24271943 DOI: 10.1007/s40273-013-0119-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The provision of stress ulcer prophylaxis (SUP) for the prevention of clinically significant bleeding is widely recognized as a crucial component of care in critically ill patients. Nevertheless, SUP is often provided to non-critically ill patients despite a risk for clinically significant bleeding of roughly 0.1 %. The overuse of SUP therefore introduces added risks for adverse drug events and cost, with minimal expected benefit in clinical outcome. Historically, histamine-2-receptor antagonists (H2RAs) have been the preferred agent for SUP; however, recent data have revealed proton pump inhibitors (PPIs) as the most common modality (76 %). There are no high quality randomized controlled trials demonstrating superiority with PPIs compared with H2RAs for the prevention of clinically significant bleeding associated with stress ulcers. In contrast, PPIs have recently been linked to several adverse effects including Clostridium difficile diarrhea and pneumonia. These complications have substantial economic consequences and have a marked impact on the overall cost effectiveness of PPI therapy. Nevertheless, PPI use remains widespread in patients who are at both high and low risk for clinically significant bleeding. This article will describe the utilization of PPIs for SUP and present the clinical and economic consequences linked to their use/overuse.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N 59th Avenue, Glendale, AZ, 85308, USA,
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