成人急性住院患者中抑酸剂的预防性使用：系统评价与荟萃分析和试验序贯分析
Prophylactic use of acid suppressants in adult acutely ill hospitalised patients: A systematic review with meta-analysis and trial sequential analysis.
机构信息
Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark.
出版信息
Acta Anaesthesiol Scand. 2020 Jul;64(6):714-728. doi: 10.1111/aas.13568. Epub 2020 Mar 5.
BACKGROUND
Acutely ill patients are at risk of stress-related gastrointestinal (GI) bleeding and prophylactic acid suppressants are frequently used. In this systematic review, we assessed the effects of stress ulcer prophylaxis (SUP) with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) versus placebo or no prophylaxis in acutely ill hospitalised patients.
METHODS
We conducted the review according to the PRISMA statement, the Cochrane Handbook and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). The primary outcomes were all-cause mortality, clinically important GI bleeding and serious adverse events (SAEs). The primary analyses included overall low risk of bias trials.
RESULTS
We included 65 comparisons from 62 trials (n = 9713); 43 comparisons were from intensive care units. Only three trials (n = 3596) had overall low risk of bias. We did not find an effect on all-cause mortality (RR 1.03, 95% CI 0.94 to 1.14; TSA-adjusted CI 0.90 to 1.18; high certainty). The rate of clinically important GI bleeding was lower with SUP (RR 0.62, 95% CI 0.43 to 0.89; TSA-adjusted CI 0.14 to 2.81; moderate certainty). We did not find a difference in pneumonia rates (moderate certainty). Effects on SAEs, Clostridium difficile enteritis, myocardial ischaemia and health-related quality of life (HRQoL) were inconclusive due to sparse data. Analyses of all trials regardless of risk of bias were consistent with the primary analyses.
CONCLUSIONS
We did not observe a difference in all-cause mortality or pneumonia with SUP. The incidence of clinically important GI bleeding was reduced with SUP, whereas any effects on SAEs, myocardial ischaemia, Clostridium difficile enteritis and HRQoL were inconclusive.
STUDY REGISTRATION
PROSPERO registration number CRD42017055676; published study protocol: Marker, et al 2017 in Systematic Reviews.
背景
危重病患者有发生应激相关胃肠道（GI）出血的风险，常预防性使用抑酸剂。在本系统评价中，我们评估了质子泵抑制剂（PPIs）或组胺 2 受体拮抗剂（H2RAs）与安慰剂或不进行预防治疗相比，用于急性住院患者应激性溃疡预防（SUP）的效果。
方法
我们根据 PRISMA 声明、Cochrane 手册和 GRADE 进行了综述，使用常规荟萃分析和试验序贯分析（TSA）。主要结局是全因死亡率、临床重要的 GI 出血和严重不良事件（SAE）。主要分析包括整体低偏倚风险的试验。
结果
我们纳入了 62 项试验中的 65 项比较（n=9713）；其中 43 项比较来自重症监护病房。仅有 3 项试验（n=3596）整体低偏倚风险。我们没有发现 SUP 对全因死亡率有影响（RR 1.03，95%CI 0.94 至 1.14；TSA 调整后的 CI 0.90 至 1.18；高确定性）。SUP 降低了临床重要的 GI 出血发生率（RR 0.62，95%CI 0.43 至 0.89；TSA 调整后的 CI 0.14 至 2.81；中等确定性）。我们没有发现肺炎发生率有差异（中等确定性）。由于数据稀疏，对 SAE、艰难梭菌肠炎、心肌缺血和健康相关生活质量（HRQoL）的影响尚无定论。无论偏倚风险如何，对所有试验的分析均与主要分析一致。
结论
我们没有观察到 SUP 对全因死亡率或肺炎的影响。SUP 降低了临床重要的 GI 出血发生率，而对 SAE、心肌缺血、艰难梭菌肠炎和 HRQoL 的任何影响尚无定论。
研究注册
PROSPERO 注册号 CRD42017055676；已发表的研究方案：Marker 等人，2017 年在系统评价中。
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