Stress Ulcer Prophylaxis: Gastrointestinal Bleeding and Nosocomial Pneumonia Best Evidence Synthesis

PURPOSE: To examine the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality. METHODS: Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files and abstract reports. Independent review of 257 articles identified 71 relevant randomized trials for inclusion. We made independent, duplicate assessment of the methodologic quality, population, intervention and outcomes of each trial. RESULTS: This overview demonstrates that prophylaxis with histamine-2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio 0.29 [95% CI 0.17-0.45]) and clinically important bleeding (odds ratio 0.35 [95% CI 0.15-0.76]). There is a trend to decreased overt bleeding when antacids are compared with no therapy (odds ratio 0.35 [95% CI 0.08-1.33]). Although sucralfate, antacids, and histamine-2-receptor antagonists are equivalent in reducing clinically important bleeding, sucralfate decreases the incidence of nosocomial pneumonia compared with antacids and/or histamine-2-receptor antagonists (odds ratio 0.50 [95% CI 0.21-0.79]). Sucralfate is associated with lower mortality relative to antacids (odds ratio 0.70 [95% CI 0.52-0.94]), and relative to histamine-2-receptor antagonists (odds ratio 0.71 [95% CI 0.49-1.04]). CONCLUSIONS: All stress ulcer prophylactic agents appear to be effective in decreasing bleeding. Prophylaxis with sucralfate is associated with a lower rate of nosocomial pneumonia and mortality, providing strong evidence for use of this agent in clinical practice.