Proton Pump Inhibitors Versus Histamine 2 Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients

Abstract

In critically ill patients, proton pump inhibitors seem to be more effective than histamine 2 receptor antagonists in preventing clinically important and overt upper gastrointestinal bleeding. The robustness of this conclusion is limited by the trial methodology, differences between lower and higher quality trials, sparse data, and possible publication bias. We observed no differences between drugs in the risk of pneumonia, death, or ICU length of stay.

Proton Pump Inhibitors in cancer patients: How useful they are? A review of the most common indications for their use

“…Randomized trials and meta-analyses support the evidence that PPIs reduce the rate of bleeding (Buendgens et al, 2016). PPIs are more effective than H2 receptor antagonists, although they failed to show any effect on overall mortality and on time of ICU stay (Krag et al, 2015;Alhazzani et al, 2013).…”

Impact of a Multifaceted Intervention on Prescribing of Proton Pump Inhibitors for Stress Ulcer Prophylaxis in the Critically Ill

“…Regarding disagreement, the primary literature deserves mention. While the majority of clinical trials demonstrate the noninferiority of H2RAs at preventing clinically significant gastric bleeding, some suggest that PPIs are a preferred treatment option (5,11).…”

“…Disease severity can range from endoscopic evidence of mucosal damage to clinically significant bleeding. Larger studies assessing the presence of mucosal damage report prevalence rates of any extent of damage in roughly 75% -100% of critically ill patients, while clinically significant bleeding occurs on average in < 0.5% -6% of patients (2)(3)(4)(5). Risk factors associated with the development of stressrelated mucosal disease have been recognized, including continuous mechanical ventilation for greater than 48 hours and coagulopathy (1).…”

Stress ulcer prophylaxis in critical illness: a Canadian survey

“…Nevertheless, SUP is a common practice, as supported by several randomized trials and the guidelines of the Surviving Sepsis Campaign, although SUP does not appear to influence the risk of death in ICU patients. 13,14,18 Regarding interest in re-evaluating SUP in a RCT comparing placebo with PPI, 85% of physicians agreed that a trial is necessary due to their concerns about lack of benefit and possible harmful effects of acid suppression. In Australia, the pilot randomized POPUP (Pantoprazole Or Placebo for Stress Ulcer Prophylaxis) trial of 214 patients was recently completed on this topic (trial registration no., ACTRN126130 00807752).…”

“…The study at issue showed that PPIs were associated with a 60% relative risk reduction in clinically important stress ulcer-related GI bleeding when compared with H2RAs. 13 In this survey, the agents of choice for SUP were ranitidine in the H2RA class and pantoprazole in the PPI class. Regardless of the agent used, the respondents cited enteral as the preferred method of administration, which is similar to survey findings among Australian prescribers.…”