Supportive and Preventive Medicine
Meta-analyses have failed to show an association between H2RAs and PPIs on the risk of pneumonia
205); a network meta-analysis conducted and published with the most recent clinical practice
However, patients concurrently receiving enteral nutrition and SUP were found to be at increased
| d. | In two large pharmacoepidemiologic cohorts, an increase in the propensity-adjusted odds of |
|---|
pneumonia occurred with PPIs compared with H2RAs (OR 1.2; CI, 1.03–1.41) in mechanically
after propensity matching (OR 1.19; CI, 1.03–1.38) (BMJ 2013;347:f5416).
Many of the trials included in these analyses had varying definitions of pneumonia.
CDI
A pharmacoepidemiologic cohort study found that CDI rates were significantly higher with PPIs
A large retrospective study found PPI use to be an independent risk factor for developing CDI in
No prospective trials have been large enough to evaluate the risk of CDI in ICU patients.
| d. | Many published trials have different definitions of CDI, unclear association of antisecretory therapy |
|---|
initiation and CDI diagnosis, and variable infection control practices.
In the SUP-ICU trial, there was no difference in infectious adverse events (new-onset pneumonia or
CDI).
There also were no differences in infectious adverse events (ventilator-associated pneumonia [VAP] in
ICU, CDI in hospital) between the pantoprazole and placebo groups in the REVISE trial.
SUP duration should be evaluated daily, and SUP should be discontinued as long as no risk factors are
present.
According to the landmark trial comparing H2RAs with sucralfate, H2RAs may be more cost-effective
because of a reduced incidence of bleeding without an increase in pneumonia rates (N Engl J Med
1998;338:791-7).
bleeding and adverse effects (VAP and CDI).
Use of PPI therapy for SUP resulted in a $1250 net cost savings per patient compared with
H2RAs. Univariate sensitivity analysis showed that PPI therapy was not as cost-effective when the
probability of VAP rates was altered (Value Health 2013;16:14-22).
Use of H2RA therapy for SUP resulted in a $1095 net cost savings compared with PPIs. Univariate
sensitivity analysis showed that assumptions of pneumonia and bleeding rates were the primary
Initiating SUP in patients at risk and appropriately discontinuing SUP when a patient no longer has any
of the risk factors for stress-related bleeding is the best practice for cost minimization.
Guideline Recommendations
In 1999, the first guideline from the American Society of Health-System Pharmacists was published
H2RAs, antacids, or sucralfate according to safety profile, costs, and ease of administration.
cytoprotective agents, H2RAs, or PPIs; antacids were not recommended (www.east.org).
2014;61:C4811).