当前位置:科学网首页 > 小柯机器人 >详情
质子泵抑制剂与组胺受体阻滞剂预防机械通气ICU患者应激性溃疡所致死亡率相差不大
作者:小柯机器人 发布时间:2020/1/23 9:54:20

新西兰惠灵顿医院Paul J. Young课题组取得一项新突破。他们的最新研究比较了质子泵抑制剂与组胺-2受体阻滞剂预防有创机械通气的ICU患者应激性溃疡对住院死亡率的影响。该项研究成果发表在2020年1月17日出版的《美国医学会杂志》上。

质子泵抑制剂(PPIs)或组胺-2受体阻滞剂(H2RBs)是重症监护室(ICU)中常用的应激性溃疡预防药物。这两种药物对死亡率的影响差异尚未清楚。

为了比较PPIs和H2RBs防治住院患者应激性溃疡的死亡率,2016年8月至2019年1月,研究组在5个国家的50个ICU中进行了一项集群交叉随机临床试验。对ICU入院24小时内需进行有创机械通气的患者进行为期90天的随访。

按照随机顺序将ICU分组,其中25个ICU(13436名患者)先使用PPIs治疗,6个月后再使用H2RBs治疗;25个ICU(13392名患者)先使用H2RBs治疗,6个月后再使用PPIs治疗。

参与者的平均年龄为58岁,共有26771名患者进入最终分析。PPI组中有18.3%的患者在治疗90天内院内死亡,H2RB组中为17.5%,差异无统计学意义。预计PPI组中有4.1%的患者实际接受了H2RBs治疗,H2RB组中有20.1%的患者实际接受了PPIs治疗。

PPI组中有1.3%的患者发生临床重大上消化道出血,显著低于H2RB组(1.8%)。两组间艰难梭菌感染、ICU及住院时间无显著差异。PPI组中有1例患者发生过敏反应。

总之,在需要机械通气的ICU患者中,使用PPIs和H2RBs预防应激性溃疡导致的住院死亡率相差不大,但该结果可能受到药物使用交叉的影响。

附:英文原文

Title: Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation: The PEPTIC Randomized Clinical Trial

Author: Paul J. Young, Sean M. Bagshaw, Andrew B. Forbes, Alistair D. Nichol, Stephen E. Wright, Michael Bailey, Rinaldo Bellomo, Richard Beasley, Kathy Brickell, Glenn M. Eastwood, David J. Gattas, Frank van Haren, Edward Litton, Diane M. Mackle, Colin J. McArthur, Shay P. McGuinness, Paul R. Mouncey, Leanlove Navarra, Dawn Opgenorth, David Pilcher, Manoj K. Saxena, Steve A. Webb, Daisy Wiley, Kathryn M. Rowan

Issue&Volume: January 17, 2020

Abstract:

Importance  Proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs) are often prescribed for patients as stress ulcer prophylaxis drugs in the intensive care unit (ICU). The comparative effect of these drugs on mortality is unknown.

Objective  To compare in-hospital mortality rates using PPIs vs H2RBs for stress ulcer prophylaxis.

Design, Setting, and Participants  Cluster crossover randomized clinical trial conducted at 50 ICUs in 5 countries between August 2016 and January 2019. Patients requiring invasive mechanical ventilation within 24 hours of ICU admission were followed up for 90 days at the hospital.

Interventions  Two stress ulcer prophylaxis strategies were compared (preferential use with PPIs vs preferential use with H2RBs). Each ICU used each strategy sequentially for 6 months in random order; 25 ICUs were randomized to the sequence with use of PPIs and then use of H2RBs and 25 ICUs were randomized to the sequence with use of H2RBs and then use of PPIs (13436 patients randomized by site to PPIs and 13392 randomized by site to H2RBs).

Main Outcomes and Measures  The primary outcome was all-cause mortality within 90 days during index hospitalization. Secondary outcomes were clinically important upper gastrointestinal bleeding, Clostridioides difficile infection, and ICU and hospital lengths of stay.

Results  Among 26982 patients who were randomized, 154 opted out, and 26828 were analyzed (mean [SD] age, 58 [17.0] years; 9691 [36.1%] were women). There were 26771 patients (99.2%) included in the mortality analysis; 2459 of 13415 patients (18.3%) in the PPI group died at the hospital by day 90 and 2333 of 13356 patients (17.5%) in the H2RB group died at the hospital by day 90 (risk ratio, 1.05 [95% CI, 1.00 to 1.10]; absolute risk difference, 0.93 percentage points [95% CI, 0.01 to 1.88] percentage points; P=.054). An estimated 4.1% of patients randomized by ICU site to PPIs actually received H2RBs and an estimated 20.1% of patients randomized by ICU site to H2RBs actually received PPIs. Clinically important upper gastrointestinal bleeding occurred in 1.3% of the PPI group and 1.8% of the H2RB group (risk ratio, 0.73 [95% CI, 0.57 to 0.92]; absolute risk difference, 0.51 percentage points [95% CI, 0.90 to 0.12 percentage points]; P=.009). Rates of Clostridioides difficile infection and ICU and hospital lengths of stay were not significantly different by treatment group. One adverse event (an allergic reaction) was reported in 1 patient in the PPI group.

Conclusions and Relevance  Among ICU patients requiring mechanical ventilation, a strategy of stress ulcer prophylaxis with use of proton pump inhibitors vs histamine-2 receptor blockers resulted in hospital mortality rates of 18.3% vs 17.5%, respectively, a difference that did not reach the significance threshold. However, study interpretation may be limited by crossover in the use of the assigned medication.

DOI: 10.1001/jama.2019.22190

Source: https://jamanetwork.com/journals/jama/fullarticle/2759412

期刊信息

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
投稿链接:http://manuscripts.jama.com/cgi-bin/main.plex