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Meta-Analysis
. 2016 May 4;20(1):120.
doi: 10.1186/s13054-016-1305-6.

Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials

Fayez Alshamsi  1   2 , Emilie Belley-Cote  3 , Deborah Cook  1   3 , Saleh A Almenawer  3   4 , Zuhoor Alqahtani  3 , Dan Perri  1 , Lehana Thabane  3 , Awad Al-Omari  5   6 , Kim Lewis  1 , Gordon Guyatt  1   3 , Waleed Alhazzani  7   8   9
Affiliations
Meta-Analysis

Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials

Fayez Alshamsi et al. Crit Care. .

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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Figures

Fig. 1
Fig. 1
Process of identifying eligible studies: 18 trials (5 abstracts and 13 full published articles) were eligible and were included in the qualitative and quantitative analyses. RCT randomized controlled trial
Fig. 2
Fig. 2
Clinically important gastrointestinal bleeding. Data from 14 trials (n = 1679 patients) are included, analyzed using the random effects model. Proton pump inhibitors (PPIs) were associated with a significantly lower risk of clinically important bleeding compared to histamine-2-receptor antagonists (H2RAs). IV Inverse Variance
Fig. 3
Fig. 3
Overt upper gastrointestinal bleeding. Data from 17 trials (n = 1897 patients) are included, analyzed using the random effects model. Proton pump inhibitors (PPIs) were associated with a significantly lower risk of overt bleeding compared to histamine-2-receptor antagonists (H2RAs). IV Inverse Variance
Fig. 4
Fig. 4
Pneumonia outcome. Data from 12 trials (n = 1471 patients) were included, analyzed using the random effects model. The risk of pneumonia was similar in both groups. PPI proton pump inhibitor, H2RA histamine-2-receptor antagonist. IV Inverse Variance
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References

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