STRESS ULCER PROPHYLAXIS USING PROTON PUMP INHIBITORS OR HISTAMINE TYPE-2 RECEPTOR ANTAGONISTS IN MECHANICALLY VENTILATED PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: The use of stress ulcer prophylaxis (SUP) is routine in the intensive care unit (ICU) to prevent serious deleterious effects of gastrointestinal bleeding (GIB). There is debate over which choice of drug is safest in the ICU setting for SUP. This literature review looks at the role of proton pump inhibitors (PPIs) compared to histamine type-2 receptor antagonists (H2RAs) and the efficacy of each drug class in regards to clinically significant/overt GIB (CS/O-GIB), ventilator associated pneumonia (VAP), ICU mortality, and ICU length of stay. METHODS: A thorough search of the literature was conducted to perform a meta-analysis of the available studies that investigated the efficacy of PPIs compared to H2RAs in the ICU for SUP among mechanically ventilated patients. This search was performed using PubMed, Embase, and Cochrane for data on the subject matter of study from inception to April 20, 2021. We considered only randomized controlled trials for this analysis. From each study, we collected the number of patients who underwent treatment with either a PPI or H2RA while intubated. The primary outcome was the occurrence of CS/O-GIB. Secondary outcomes were the occurrence of VAP, ICU mortality, and ICU length of stay. The random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CIs). A p-value <0.05 was considered statistically significant. Heterogeneity was assessed using Higgins I2 index. RESULTS: Seven randomized controlled trials involving 27905 patients were including in the meta-analysis. The rate of CS/O-GIB was significantly lower in patients receiving PPIs when compared to those receiving H2RAs while intubated (1.6% vs. 2.5%, RR 0.59, 95% CI 0.45-0.79, p= 0.0003, I2= 31%). Five studies reported the rate of VAP, which was not significantly lower in either the PPIs group or the H2RAs group (12.1% vs. 11.4%, RR 1.10, 95% CI 0.74-1.62, p= 0.64, I2= 0%). Five studies reported the rates of ICU mortality in intubated patients, which was not significantly lower in patients receiving PPIs or H2RAs (0.73% vs. 0.70%, RR 1.05, 95% CI 0.86-1.30, p= 0.62, I2= 0%). Four studies reported ICU length of stay, which was found to be similar in both patients receiving PPIs or H2RAs (MD= 0.02 days, 95% CI -0.12-0.16, p= 0.70, I2= 32%). CONCLUSIONS: Our meta-analysis demonstrates that the use of PPIs for mechanically ventilated patients when compared to H2RAs, significantly reduced the rate of CS/O-GIB. The rate of VAP is not significantly lower in either the PPI or H2RA group. Also, there is no significant reduction in the ICU mortality or ICU length of stay when PPIs are used instead of H2RAs. Further data should be collected to confirm our findings. CLINICAL IMPLICATIONS: The use of PPIs in mechanically ventilated patients is effective in preventing CS/O-GIB when compared to H2RAs, without leading to a significant increase in the rate of VAP or ICU mortality. DISCLOSURES: No relevant relationships by Hyder Ali, source=Web Response No relevant relationships by Modar Alom, source=Web Response No relevant relationships by Mohammed Awad, source=Web Response No relevant relationships by Azizullah Beran Beran, source=Web Response No relevant relationships by prabath herath mudiyanselage, source=Web Response No relevant relationships by Saffa Iftikhar, source=Web Response No relevant relationships by Nithin Kesireddy, source=Web Response No relevant relationships by Waleed Khokher, source=Web Response No relevant relationships by Rakin Rashid, source=Web Response