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. 2018 Jan;44(1):1-11.
doi: 10.1007/s00134-017-5005-8. Epub 2017 Dec 4.

Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials

Waleed Alhazzani  1   2 , Fayez Alshamsi  3 , Emilie Belley-Cote  4 , Diane Heels-Ansdell  4 , Romina Brignardello-Petersen  4 , Mustafa Alquraini  5 , Anders Perner  6 , Morten Hylander Møller  6 , Mette Krag  6 , Saleh Almenawer  7 , Bram Rochwerg  5   4 , Joanna Dionne  5 , Roman Jaeschke  5   4 , Mohammed Alshahrani  8 , Adam Deane  9 , Dan Perri  5 , Lehana Thebane  4 , Awad Al-Omari  10   11 , Simon Finfer  12 , Deborah Cook  5   4 , Gordon Guyatt  5   4
Affiliations

Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network meta-analysis of randomized trials

Waleed Alhazzani et al. Intensive Care Med. 2018 Jan.

Erratum in

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.

Keywords: Critical illness; Histamine-2 receptor antagonists; Network meta-analysis; Pneumonia; Proton pump inhibitors; Stress ulcers; Sucralfate.

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Conflict of interest statement

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Funding

This study was funded by the Hamilton Chapter of the Canadian Intensive Care Foundation, the Critical Care Medicine Residency Program, and the Critical Care Division Alternate Funding Plan at McMaster University. Waleed Alhazzani holds a McMaster University Department of Medicine Internal Career Research Award. Deborah Cook is a Canada Research Chair of the Canadian Institutes for Health Research.

Figures

Fig. 1
Fig. 1
Flow diagram of the search results. This figure shows the process of selecting eligible studies. Overall, we included 57 randomized clinical trials from 58 reports
Fig. 2
Fig. 2
a Clinically important bleeding outcome. b Pneumonia outcome. a Test for inconsistency: p = 0.889 (indicating not inconsistent). b Test for inconsistency: p = 0.794 (indicating not inconsistent). CI confidence interval, H2RA histamine 2 receptor antagonists, PPI proton pump inhibitors
Fig. 3
Fig. 3
a Cumulative ranking curve for clinically important bleeding outcome. CIB clinically important bleeding, H2RA histamine 2 receptor antagonists, PPI proton pump inhibitors. b Cumulative ranking curve for pneumonia outcome. H2RA histamine 2 receptor antagonists, PPI proton pump inhibitors
See this image and copyright information in PMC

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