Acute stress bleeding prophylaxis with sucralfate versus ranitidine and incidence of secondary pneumonia in intensive care unit patients

Mustafa, Natasha; Akturk, Galip; Özen, İbrahim; Koksal, Ilfan; Erciyes, Nesrin; Solak, Mustafa

doi:10.1007/bf01701491

Cited by 16 publications

(7 citation statements)

References 5 publications

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“…Forty trials including 9288 patients1114394041444546474853545657596163646566676971737576798081828385909192939495979899 reported pneumonia. PPIs may increase the risk of pneumonia compared with placebo or no prophylaxis (odds ratio 1.39 (95% credible interval 0.98 to 2.10), 50 more per 1000 patients, low certainty, table 3), as may H2RAs (1.26 (0.89 to 1.85), 34 more per 1000 patients, low certainty, table 3).…”

Section: Resultsmentioning

confidence: 99%

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Wang

et al. 2020

BMJ

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ObjectiveTo determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.DesignSystematic review and network meta-analysis.Data sourcesMedline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.Eligibility criteria for selecting studies and methodsWe included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.ResultsSeventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).ConclusionsFor higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.Systematic review registrationPROSPERO CRD42019126656.

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Section: Resultsmentioning

confidence: 99%

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Wang

et al. 2020

BMJ

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“…Incidence of pneumonia with ranitidine v sucralfate (meta-analysis E) —Our fifth meta-analysis included eight randomised studies 3 19 – 26 that compared the incidence of pneumonia with ranitidine and sucralfate (five of these trials19 – 23 had already been included in the meta-analysis by Cook et al). The quality score for these trials was 5.6 (2.3).…”

Section: Resultsmentioning

confidence: 99%

Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled

Messori

2000

BMJ

224

115

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Objectives To determine the effectiveness of ranitidine and sucralfate in the prevention of stress ulcer in critical patients and to assess if these treatments affect the risk of nosocomial pneumonia. Design Published studies retrieved through Medline and other databases. Five meta-analyses evaluated effectiveness in terms of bleeding rates (A: ranitidine v placebo; B: sucralfate v placebo) and infectious complications in terms of incidence of nosocomial pneumonia (C: ranitidine v placebo; D: sucralfate v placebo; E: ranitidine v sucralfate). Trial quality was determined with an empirical ad hoc procedure. Main outcome measures Rates of clinically important gastrointestinal bleeding and nosocomial pneumonia (compared between the two study arms and expressed with odds ratios specific for individual studies and meta-analytic summary odds ratios). Results Meta-analysis A (five studies) comprised 398 patients; meta-analysis C (three studies) comprised 311 patients; meta-analysis D (two studies) comprised 226 patients: and meta-analysis E (eight studies) comprised 1825 patients. Meta-analysis B was not carried out as the literature search selected only one clinical trial. In meta-analysis A ranitidine was found to have the same effectiveness as placebo (odds ratio of bleeding 0.72, 95% confidence interval 0.30 to 1.70, P = 0.46). In placebo controlled studies (meta-analyses C and D) ranitidine and sucralfate had no influence on the incidence of nosocomial pneumonia. In comparison with sucralfate, ranitidine significantly increased the incidence of nosocomial pneumonia (meta-analysis E: 1.35, 1.07 to 1.70, P = 0.012). The mean quality score in the four analyses (on a 0 to 10 scale) ranged from 5.6 in meta-analysis E to 6.6 in meta-analysis A. Conclusions Ranitidine is ineffective in the prevention of gastrointestinal bleeding in patients in intensive care and might increase the risk of pneumonia. Studies on sucralfate do not provide conclusive results. These findings are based on small numbers of patients, and firm conclusions cannot presently be proposed.

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“…Clinically important gastrointestinal bleeding was lower in the patients receiving ranitidine (relative risk 0.44, 95% CI 0.21-0.92), but there were no significant differences between the groups in VAP rate, mortality rate, or duration of the ICU stay. However, in some studies, the use of ranitidine was associated with a higher risk of VAP than sucralfate [173][174][175], though not in other studies [172,[176][177][178][179].…”

Section: Stress Ulcer Prophylaxismentioning

confidence: 99%

“…In the meta-analysis by MESSORI et al [180], analysis of the 1,825 patients from eight studies that reported VAP rate [172][173][174][175][176][177][178][179] showed that the use of ranitidine to prevent gastrointestinal bleeding increased the VAP incidence in comparison with sucralfate (odds ratio 1.35, 95% CI 1.07-1.70); however, this meta-analysis was full of ill-designed and under-powered studies. Later, a prospective cohort study, published by BORSTAIN et al [181], of 747 patients undergoing mechanical ventilation found that sucralfate use was associated with a higher risk of early onset VAP (odds ratio 1.81, 95% CI 1.01-3.26).…”

Section: Stress Ulcer Prophylaxismentioning

confidence: 99%

Evidence on measures for the prevention of ventilator-associated pneumonia

Lorente

Blot²,

Rello³

2007

European Respiratory Journal

134

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Acute stress bleeding prophylaxis with sucralfate versus ranitidine and incidence of secondary pneumonia in intensive care unit patients

Cited by 16 publications

References 5 publications

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled

Evidence on measures for the prevention of ventilator-associated pneumonia

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