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Stress Gastritis Prevention-- A Tale of Two Drugs The Efficacy and Safety of Proton Pump Inhibitors vs Histamine-2 Receptor Antagonists for Stress Ulcer Bleeding Prophylaxis Among Critical Care Patients : A Meta-Analysis
| Content Provider | Semantic Scholar |
|---|---|
| Author | Chang |
| Copyright Year | 2010 |
| Abstract | Background: Stress gastritis continues to occur in critically ill patients especially when prophylactic measures are not used. Even with prophylaxis, clinically important bleeding occurs in 2 to 4% of patients. Objective: To compare effectiveness of histamine-2 (H2) blockers and proton pump inhibitors (PPIs) as prophylactic agents for stress gastritis. Design: Meta-analysis of English articles where selection criteria initially identified 1213 studies. Participants: 936 patients in 7 randomized controlled trials. Methods: All studies compared PPIs to an H2 blocker. Efficacy was measured by incidence of stress gastritis bleeding. Safety outcome was measured by the rate of pneumonia and mortality. Quality of the study was ranked using Jadad criteria. Of trials, 3 reported on the use of enteral nutrition. A definition of upper gastrointestinal (UGI) bleeding was defined in 5 trials and 6 trials reported pneumonia rates. Sensitivity analysis was performed to help identify heterogeneity. Results were reported as pooled risk difference between the two different drug classes. Omeprazole was used in 6 studies and pantoprazole in one study. H2 blockers used included ranitidine, famotidine, and cimetidine. Most studies had 30 patients per study arm with only 1 study having >100 patients in each study group. Results: Pooled risk difference for UGI bleeding was -0.04 favoring PPIs which was not statistically significant. However, there was significant heterogeneity among studies. Sensitivity analysis revealed little effect on results except when the largest study was removed, which reduced heterogeneity and shifted reduced the risk difference between the 2 drugs. Risk of pneumonia ranged from 3 to 18% and there was no difference in rates based on which drug was used. Mortality was also not different. Of studies, 3 were poor quality and 4 had a Jadad score consistent with good quality. Conclusions: Current evidence does not support an effectiveness difference between H2 blockers and PPIs when used for stress gastritis prophylaxis. Reviewer's Comments: H2 blockers and PPIs are equally as effective for preventing UGI bleeding from stress gastritis and neither is associated with an increased rate of pneumonia. I doubt this article will change a lot of minds on this topic. Current data are not great and the authors ask for the proverbial large randomized clinical trial. I doubt that will happen. Our approach is more pragmatic. A cost consideration drives our choice of agent. We use H2 blockers as the least costly drug in our pharmacy. If PPIs become the least costly agent, I suspect we will change. We use stress prophylaxis only for high-risk patients and stop the drug when risk characteristics of the patient change. Attention to these details will avoid drug cost and risk in many patients. (Reviewer-John A. Weigelt, MD). |
| File Format | PDF HTM / HTML |
| Alternate Webpage(s) | http://www.practicalreviews.com/My_Media/PDF/General%20Surgery,%20July%2030%202010.pdf |
| Language | English |
| Access Restriction | Open |
| Content Type | Text |
| Resource Type | Article |
