New Guidelines Address Gastrointestinal Bleeding Prophylaxis

A new set of recommendations for treating critically ill patients with gastrointestinal bleeding prophylaxis call for the use of proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs), despite an increased risk of pneumonia.

Zhikang Ye, Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, led a panel that included patients, clinicians, and methodologists that developed recommendations using standards for trustworthy guidelines and the GRADE approach, a systematic technique to rating the certainty of evidence in systematic reviews and other evidence syntheses.

The new recommendations are based on a linked systematic and network meta-analysis. A weak recommendation means that both options are reasonable.

One of the recommendations in the new guideline is the suggestion on using acid suppression for people with higher risk of gastrointestinal bleeding—4% or higher.

The second new recommendation is for critically ill patients who are going to receive prophylaxis against gastrointestinal bleeding to use a PPI or H2RA. However, they do not suggest using sucralfate for this patient population.

“The panel identified risk categories based on evidence, with variable certainty regarding risk factors,” the authors wrote. “The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation).”

While gastric acid suppression with proton pump inhibitors or histamine-2 receptor antagonists are commonly done to prevent gastrointestinal bleeding in critically ill patients, existing guidelines vary in their recommendations to which population to treat and which agent to use.

“This guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%),” the authors wrote.

The new guidelines are a direct result of the publication of a new large, randomized controlled study involving 12,660 critically ill patients in 72 trials. The investigators found reviewing 12,660 critically ill patients in 72 trials that both treatments—PPIs and H2RAs—reduce the risk of clinically important bleeding.

They also found with moderate certainty that the effect is larger in patients at higher bleeding risk—those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock.

However, these medicines may also increase the risk of pneumonia (low certainty) and probably do not have an effect on mortality (moderate certainty), length of hospital stays, or other relevant outcomes. PPIs likely reduce the risk of bleeding more than H2RAs (moderate certainty).

“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 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.”

On average, 4% of critically ill patients develop gastrointestinal bleeding, with a leading causing being physiologic stress that cause stress ulcers in the esophagus, stomach or duodenum. Critical illness is also linked with other forms of upper gastrointestinal bleeding.

The study, “Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline,” was published online in The BMJ.