Is prophylaxis against gastrointestinal bleeding effective in critically ill patients?

For critically ill patients with a greater than 4% risk of bleeding (eg, those with chronic liver disease or coagulopathy, and patients on mechanical ventilation without enteral nutrition), proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) decrease the risk of clinically important bleeding, as compared with no prophylaxis. (LOE = 1a)

Wang Y, Ye Z, Ge L, et al. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis. BMJ 2020;368:l6744.  [PMID:31907166]

Meta-analysis (randomized controlled trials)

Government

Uncertain

Inpatient (ICU only)

Patients in intensive care units routinely receive PPIs or, less commonly, H2RAs for prophylaxis against gastrointestinal (GI) bleeding and stress ulcers. In this study, investigators updated their previous systematic review by identifying randomized controlled trials through March 2019 that compared agents for GI bleeding prophylaxis (PPIs, H2RAs, sucralfate) with one another, placebo, or no prophylaxis in critically ill, adult patients. Two reviewers independently selected studies, extracted data, and assessed the risk of bias. Overall, 72 studies were included with a total of 12,660 patients. For patients at high risk (>4% to 8%) and highest risk (>8%) of bleeding, both PPIs and H2RAs reduced clinically important GI bleeding as compared with placebo or no prophylaxis (PPIs: odds ratio [OR] 0.61; 95% CI 0.42 - 0.89; H2RAs: OR 0.46; 0.27 - 0.79). Patients at lower risk for bleeding had smaller, less important effects. No significant difference was detected when comparing PPIs with H2RAs for lowering the risk of bleeding and sucralfate did not fare well in comparison with either class of drugs. Additionally, there were no differences in mortality, incidence of pneumonia or Clostridium difficile infection, length of intensive care stay or hospital stay, or duration of mechanical ventilation with the use of PPIs/H2RAs as compared with placebo or no prophylaxis.