GI bleeding prophylaxis recommended in high-risk critically ill patients

Proton-pump inhibitors appeared to reduce bleeding risk more than histamine-2 receptor antagonists.

Critically ill patients considered to be at high risk for gastrointestinal (GI) bleeding may benefit from prophylaxis, according to a recent Rapid Recommendation statement from the BMJ.

The statement was developed by a guideline panel and is based on a systematic review and meta-analysis that evaluated the efficacy and safety of GI bleeding prophylaxis with proton-pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), or sucralfate, as well as no prophylaxis, in critically ill patients in the intensive care unit. Both the statement and the review and meta-analysis were published by the BMJ on Jan. 6.

The review and meta-analysis included 72 trials involving 12,660 patients and found that both PPIs and H2RAs decreased risk for clinically important GI bleeding, especially in those at higher risk. The review also found that both types of treatment may increase risk for pneumonia versus no prophylaxis but probably do not affect mortality or other important outcomes. PPIs appeared to reduce bleeding risk more than H2RAs, the review noted.

The guideline panel made a weak recommendation for use of GI bleeding prophylaxis in critically patients at high risk for clinically important GI bleeding, defined as greater than 4%, and against prophylaxis in those at lower risk. The panel suggested that a PPI be used rather than an H2RA (weak recommendation) and recommended against using sucralfate (strong recommendation). The panel noted that clinicians should ensure acid suppression medications are stopped after patients recover from their critical illness or are no longer considered at risk for GI bleeding, unless another indication for prophylaxis is present.

“In most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia,” the statement authors wrote. “Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis.”