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Evidence summaries

Histamine-2-Receptor Antagonists and Antacids in Critically Ill Patients

Both histamine-2-receptor antagonists and sucralfate are effective in reducing overt bleeding in critically ill patients who are mechanically ventilated or who have coagulopathy. Sucralfate may reduce the incidence of pneumonia and total mortality. Level of evidence: "A"

A systematic review 1 including 63 studies and 3 overviews was abstracted in DARE. Histamine-2-receptor antagonists reduced overt bleeding compared with placebo or no therapy (common odds ratio 0.29, 95% CI 0.17 to 0.45). Antacids also reduced overt bleeding (OR 0.40), but histamine-2-receptor antagonists were more effective than antacids (OR 0.56, 95% CI 0.33 to 0.97). Both histamine-2-receptor antagonists (OR 0.35) and antacids (OR 0.35) reduced clinically important bleeding. Sucralfate reduced the incidence of pneumonia compared with two gastric pH-altering agents (OR 0.50, 95% CI 0.21 to 0.79). Sucralfate was associated with a lower mortality rate than antacid therapy (OR 0.70, 95% CI 0.52 to 0.94).

A later systematic review 2 by the same authors abstracted in DAREincluded 63 RCTs with a total of 7,218 subjects. Histamine-2-receptor antagonists significantly reduced overt bleeding in comparison to placebo therapy, OR 0.58 (95% CI 0.42 to 0.79) and in comparison to antacid therapy (OR 0.44, 95% CI 0.37 to 0.84). Sucralfate significantly decreased overt bleeding in comparison to no prophylaxis (OR 0.58, 95% CI 0.34 to 0.99). Sucralfate was associated with a statistically significant reduction in mortality when compared to antacids, OR 0.74 (95% CI 0.54 to 0.97). A trend in favour of sucralfate over histamine-2-receptor antagonists was also demonstrated.

Comment: There is indirectness of evidence: proton-pump inhibitors (ppi) are used at present instead of histamine-2-receptor antagonists, and this old review does not include studies comparing sucralfate and ppi.

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    References

    • Cook DJ, Reeve BK, Scholes LC. Histamine-2-receptor antagonists and antacids in the critically ill population: stress ulceration versus nosocomial pneumonia. Infect Control Hosp Epidemiol 1994 Jul;15(7):437-42. [PubMed] [DARE]
    • Cook DJ, Reeve BK, Guyatt GH, Heyland DK, Griffith LE, Buckingham L, Tryba M. Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. JAMA 1996 Jan 24-31;275(4):308-14. [PubMed] [DARE]

Primary/Secondary Keywords