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

Abstract

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.

Multivariate analysis of the factors associated with the risk of pneumonia in intensive care units

“…In 47% of these patients there was a growth of Gram-negative bacilli, while in patients with gastric pH < 4, cultures were sterile. A metaanalysis carried out by Messori et al [10] concluded that ranitidine is ineffective in preventing gastrointestinal bleeding and increases the risk of pneumonia.…”

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

“…Hence, it is difficult to recommend against H 2 blockers or proton pump inhibitors. Sucralafate may indeed be superior from the viewpoint of VAP, but it is less effective with regard to prophylaxis of gastrointestinal bleeding, and thus it use is not warranted over H 2 blockers or proton pump inhibitors (16,37,143).…”

Stress ulcer prophylaxis guidelines: Are they being implemented in Lebanese health care centers?

“…According to ASHP guidelines on SUP, histamine 2 antagonists (H2-RAs), antacids, and sucralfate are recommended for the prevention of stress ulcers. The choice of the drug is institution-specific [9,[23][24][25][26][27] and should take into account concerns regarding ease of administration, adverse events and cost [4,26,28] . When the ASHP guidelines were published, there was insufficient data available on the efficacy and safety of misoprostol and proton pump inhibitors (PPIs) to allow their recommendation.…”