GI-bleeding prophylaxis benefits higher-risk critically ill patients

Last Updated: 2020-01-23

By Reuters Staff

NEW YORK (Reuters Health) - Prophylaxis with proton-pump inhibitors (PPIs) or histamine-2-receptor antagonists (H2RAs) significantly reduces gastrointestinal bleeding in higher-risk critically ill patients, but not in patients at low risk of bleeding, according to a systematic review and network meta-analysis.

Gastrointestinal (GI)-bleeding prophylaxis is commonly used to reduce the elevated risk of gastrointestinal bleeding in critically ill patients in intensive-care units. This practice is increasingly questioned in light of new evidence suggesting a decrease in the frequency of bleeding in these patients, along with evidence that acid-suppressive drugs might increase the risk of nosocomial pneumonia and Clostridioides difficile infection.

Dr. Lihong Liu of Beijing Chaoyang Hospital, Capital Medical University, in China, and colleagues conducted a systematic review and network meta-analysis on the potential benefits and harms of GI-bleeding prophylaxis with PPIs, H2RAs and sucralfate in critically ill patients.

Findings from 43 trials including more than 10,000 patients indicated that, for patients at highest (>8%) and high (>4-8%) risk of bleeding, both PPIs and H2RAs reduce the risk of clinically important gastrointestinal bleeding, compared with placebo or no prophylaxis (with moderate certainty).

For patients at lower risk of bleeding, the absolute effects of bleeding prophylaxis are unlikely to be clinically meaningful, the researchers say in The BMJ.

Estimates from 51 trials indicated that PPIs and H2RAs have no meaningful impact on mortality.

PPIs and H2RAs might increase the risk of pneumonia, although both 95% confidence intervals included 1.0, and it remains unclear whether PPIs increase the risk of C. difficile infection.

None of the interventions appear to influence intensive care or hospital length of stay or to influence the duration of mechanical intervention.

Based on these findings, Dr. Liu and a panel of patients, clinicians, and methodologists produced a clinical practice guideline that included these recommendations, also in The BMJ:

- A weak recommendation for using GI-bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important GI bleeding;

- a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding;

- a weak recommendation to favor using a PPI rather than a H2RA for prophylaxis; and

- a strong recommendation against using sucralfate for prophylaxis.

Dr. Liu did not respond to a request for comments.

SOURCE: https://bit.ly/38C9wkr and https://bit.ly/30LqPwU The BMJ, online January 6, 2020.