title: Proton pump inhibitors vs. histamine 2 receptor antagonists for stress-related mucosal bleeding prophylaxis in critically ill patients: a meta-analysis.
abstract: OBJECTIVE
  H2-receptor antagonists (H2RA) have been shown to reduce stress-related mucosal bleeding (SRMB), yet randomized controlled trials assessing proton pump inhibitors (PPIs) have yielded conflicting results. The objective of this study was to evaluate the efficacy of PPIs vs. H2RAs in the prophylaxis of SRMB in critically ill adults with risk factors for bleeding.
  
  
  METHODS
  Tailored literature searches of the past four decades were conducted. Outcomes measured were the decreases in rates of clinically significant bleeding (B, primary outcome of the meta-analysis), nosocomial pneumonia (P), and mortality (M) (secondary outcomes). Study heterogeneity was sought and quantified. Results are reported as odd ratios (ORs) with 95% confidence intervals (CIs).
  
  
  RESULTS
  Eight fully published randomized controlled trials and five abstracts met the inclusion criteria. Prophylactic PPI administration significantly decreased the incidence of bleeding (N = 1,587 patients, OR = 0.30; 95% CI: 0.17-0.54), number needed to treat = 39; 95% CI: 21-303 with no observed statistical heterogeneity among the relevant comparisons (P = 0.93, I2 = 0.0%). No statistical differences were noted for the development of nosocomial pneumonia (n = 7, N = 1,017 patients, OR = 1.05; 95% CI: 0.69-1.62) or mortality (n = 8, N = 1,260 patients, OR = 1.19; 95% CI: 0.84-1.68) or (and no heterogeneity was found for either: P = 0.85, I2 = 0.0%, and P = 0.96, I2 = 0%, respectively).
  
  
  CONCLUSIONS
  In critically ill patients at risk for the development of SRMB, PPI prophylaxis significantly decreased rates of clinically significant bleeding compared with H2RA, without affecting the development of nosocomial pneumonia or mortality rates. The magnitude of the beneficial effect, and its clinical relevance, now requires further characterization using cost-effectiveness analysis considering the incidence of stress-related mucosal disease-related bleeding.
authors.affiliation: Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Québec, Canada. alan.barkun@muhc.mcgill.ca
authors.forename: Alan N
authors.initials: AN
authors.lastname: Barkun
authors.forename: Marc
authors.initials: M
authors.lastname: Bardou
authors.forename: C Q D
authors.initials: CQ
authors.lastname: Pham
authors.forename: Myriam
authors.initials: M
authors.lastname: Martel
mesh_terms: D016638:Critical Illness; D006471:Gastrointestinal Hemorrhage / Q000209:etiology* / Q000517:prevention & control*; D006635:Histamine H2 Antagonists / Q000627:therapeutic use*; D006801:Humans; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D013315:Stress, Psychological
chemical_list: D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors