Re‐evaluating the Utility of Stress Ulcer Prophylaxis in the Critically Ill Patient: A Clinical Scenario‐Based Meta‐Analysis

MacLaren, Robert

doi:10.1002/phar.2172

Cited by 27 publications

(42 citation statements)

References 55 publications

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“…Firstly, our meta-analysis has a larger sample size. Different from the previous meta-analysis [14][15][16][17], our study included the SUP-ICU trial [18], in which the number of the subject is more than 3000, which are larger than the total number of subjects in all previous trials. Therefore, our meta-analysis with a larger sample size would decrease the sampling errors and selective bias to some extent and reveal the outcome effects more objectively [21].…”

Section: Discussionmentioning

confidence: 99%

“…Proton pump inhibitors (PPI) and histamine2 receptor antagonists (H2RA) have been used as stress ulcer prophylaxis (SUP) in critically ill patients for more than 40 years [7], however, its efficacy and safety remain controversial. Over the past decades, numerous randomized controlled trials (RCTs) [7][8][9][10][11][12][13] were conducted to investigate the relationship of SUP and clinical outcomes in critically ill patients, several meta-analyses [14][15][16] found that SUP with PPI or H2RA was effective in preventing GI bleeding compared with placebo or no prophylaxis, however, a recent meta-analysis by Huang et al [17] concluded that SUP with PPI or H2RA had no beneficial effects on GI bleeding in ICU patients receiving enteral nutrition (EN). Meanwhile, some studies [14,17] revealed an increased risk of pneumonia with use of PPI or H2RA, but others studies [15,16] suggested that SUP with PPI or H2RA was not accompanied by increased incident of pneumonia.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis.

Zhou

Fang

et al. 2019

Preprint

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Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults.Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed.Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk(RR)= 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR= 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR=0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR=0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR=0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR=0.27; 95% CI: 0.04–2.09).Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis.

Zhou

Fang

et al. 2019

Preprint

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“…Although the 2017 SHEA/IDSA CDI guideline supports discontinuing unnecessary PPI therapy, it provides no recommendation related to deprescribing efforts to decrease CDI incidence. Further, a recent systematic review of stress ulcer prophylaxis in ICU patients receiving enteral nutrition and a clinical scenario–based meta‐analysis suggested no statistical association with CDI incidence . An analytic modeling study in the ICU supports a histamine 2 receptor antagonist strategy over PPI therapy in the ICU based on many factors including CDI risk, but despite these findings, critical care–emphasized international guidelines for sepsis have not yet declared a preference for either modality when selecting therapy for stress ulcer prophylaxis .…”

Section: Acid Suppressionmentioning

confidence: 99%

“…Further, a recent systematic review of stress ulcer prophylaxis in ICU patients receiving enteral nutrition and a clinical scenariobased meta-analysis suggested no statistical association with CDI incidence. 55,56 An analytic modeling study in the ICU supports a histamine 2 receptor antagonist strategy over PPI therapy in the ICU based on many factors including CDI risk, but despite these findings, critical care-emphasized international guidelines for sepsis have not yet declared a preference for either modality when selecting therapy for stress ulcer prophylaxis. 57,58 Systematic processes to discontinue unnecessary stress ulcer prophylaxis, particularly PPIs, in ICU patients are important.…”

Section: Acid Suppressionmentioning

confidence: 99%

Prevention of Clostridium difficile Infection in Critically Ill Adults

et al. 2019

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The incidence and severity of Clostridium difficile infection (CDI) remain high across intensive care units in the United States despite national efforts to decrease this escalating health care burden. Most published literature and guidelines address treatment rather than prevention, yet this approach may be too downstream to limit morbidity and mortality from the disease and its complications. Mechanisms to prevent CDI successfully include reducing modifiable risk factors and minimizing horizontal transmission of C. difficile spores between patients and the health care environment. Because CDI prevention is characterized by a bundled approach, it is difficult to quantify the individual impact of any one element; however, a number of patient‐ and facility‐level strategies can be considered for CDI prevention. Robust hygiene strategies, diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin in the setting of systemic antibiotics have all demonstrated benefit. The preventive roles of deprescribing acid suppressants, routine use of probiotics, or early fecal microbiota transplantation remain unclear. The focus of this review is to summarize the evidence related to primary and secondary CDI prevention in critically ill adults and provide a concise implementation pathway for clinicians and policymakers.

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“…Stress ulcer prophylaxis to prevent gastrointestinal hemorrhage is ingrained as practice dogma to the extent that most ICUs include initiation of therapy in their admission orders. A metaanalysis 6 indicated that the benefit of acid suppressants for stress ulcer prophylaxis is limited to prevention of gastrointestinal bleeding, but mortality is not changed. Moreover, two other studies 7,8 suggested that acid suppressants may be associated with multidrug-resistant pneumonia and Clostridium difficile infection, respectively.…”

Section: E D I T O R I a Lmentioning

confidence: 99%

Prevention Strategies to Improve Outcomes in Critically Ill Adults

MacLaren

Brophy

2019

Pharmacotherapy

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Re‐evaluating the Utility of Stress Ulcer Prophylaxis in the Critically Ill Patient: A Clinical Scenario‐Based Meta‐Analysis

Abstract: This meta-analysis demonstrated that SUP use was associated with significant reductions in bleeding but not mortality. SUP should not be abandoned until large randomized trials demonstrate the futility of this intervention.

Cited by 27 publications

References 55 publications

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis.

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis.

Prevention of Clostridium difficile Infection in Critically Ill Adults

Prevention Strategies to Improve Outcomes in Critically Ill Adults

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