Proton-Pump Inhibitors to Prevent Gastrointestinal Bleeding — An Updated Meta-Analysis

医学 相对风险 质子抑制剂泵 应激性溃疡 内科学 荟萃分析 安慰剂 置信区间 子群分析 随机对照试验 重症监护医学 病理 替代医学
作者
Ying Wang,Sameer Parpia,Long Ge,Diane Heels‐Ansdell,Honghao Lai,Meisam Abdar Esfahani,Bei Pan,Waleed Alhazzani,Stefan Schandelmaier,François Lauzier,Yaseen M. Arabi,Jeffrey F. Barletta,Adam M. Deane,Simon Finfer,David Williamson,Salmaan Kanji,Morten Hylander Møller,Anders Perner,Mette Krag,Paul J. Young
出处
期刊:NEJM evidence [New England Journal of Medicine]
卷期号:3 (7) 被引量:12
标识
DOI:10.1056/evidoa2400134
摘要

BackgroundThe goal of this systematic review was to examine the efficacy and safety of proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients.MethodsWe included randomized trials comparing proton-pump inhibitors versus placebo or no prophylaxis in critically ill adults, performed meta-analyses, and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. To explore the effect of proton-pump inhibitors on mortality based on disease severity, a subgroup analysis was conducted combining within-trial subgroup data from the two largest trials and assessed credibility using the Instrument for Assessing the Credibility of Effect Modification Analyses.ResultsTwelve trials that enrolled 9533 patients were included. Proton-pump inhibitors were associated with a reduced incidence of clinically important upper gastrointestinal bleeding (relative risk [RR], 0.51 [95% confidence interval (CI), 0.34 to 0.76]; high certainty evidence). Proton-pump inhibitors may have little or no effect on mortality (RR, 0.99 [95% CI, 0.93 to 1.05]; low certainty). Within-trial subgroup analysis with intermediate credibility suggested that the effect of proton-pump inhibitors on mortality may differ based on disease severity. Subgroup results raise the possibility that proton-pump inhibitors may decrease 90-day mortality in less severely ill patients (RR, 0.89; 95% CI, 0.80 to 0.98) and may increase mortality in more severely ill patients (RR, 1.08; 95% CI, 0.96 to 1.20]. Proton-pump inhibitors may have no effect on pneumonia and little or no effect on Clostridioides difficile infection (low certainty).ConclusionsHigh certainty evidence supports the association of proton-pump inhibitors with decreased upper gastrointestinal bleeding. Proton-pump inhibitors may have little or no effect on mortality, although a decrease in mortality in less severely ill patients and an increase in mortality in more severely ill patients remain possible. (PROSPERO number CRD42023461695.)
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