Department of Internal Medicine, University of Michigan, Ann Arbor; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Mich.
Department of Internal Medicine, University of Michigan, Ann Arbor; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor; Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor.
Am J Med. 2022 Oct;135(10):1231-1243.e8. doi: 10.1016/j.amjmed.2022.05.031. Epub 2022 Jun 7.
The role of antisecretory drugs for the prevention of upper gastrointestinal bleeding in patients using anticoagulants is unclear. We investigated this question in a systematic review and meta-analysis.
We searched Embase, PubMed, Web of Science, Scopus, the Cochrane Library, and clinicaltrials.gov thru April 2021 for controlled randomized trials and observational studies evaluating the association of proton pump inhibitors (PPIs) or H2-receptor antagonists with overt upper gastrointestinal bleeding in patients using anticoagulants. Independent duplicate review, data extraction, and risk of bias assessment were performed. Observational studies were included only if they provided results controlled for at least 2 variables. Meta-analyses were performed using random effects models.
Six observational studies and 1 randomized trial were included. All but 1 study had low risk of bias. None of the studies excluded patients with concomitant aspirin or nonsteroidal anti-inflammatory drug use. For PPIs, the pooled relative risk of upper gastrointestinal bleeding was 0.67 (95% confidence interval 0.61, 0.74) with low statistical heterogeneity (I = 15%). Individual studies showed greater treatment effect in patients with higher risk for upper gastrointestinal bleeding (eg, nonsteroidal anti-inflammatory drug or aspirin use, elevated bleeding risk score). A single observational study evaluating the association of H2-receptor antagonists with upper gastrointestinal bleeding found a relative risk of 0.69 (95% confidence interval 0.24-2.02).
Evidence drawn mostly from observational studies with low risk of bias demonstrate that PPIs reduce upper gastrointestinal bleeding in patients prescribed oral anticoagulants. The benefit appears to be most clearcut and substantial in patients with elevated risk of upper gastrointestinal bleeding.
抗分泌药物在预防使用抗凝剂的患者上消化道出血中的作用尚不清楚。我们通过系统评价和荟萃分析对此进行了研究。
我们通过 Embase、PubMed、Web of Science、Scopus、Cochrane Library 和 clinicaltrials.gov 检索了截止到 2021 年 4 月的对照随机试验和观察性研究，评估质子泵抑制剂 (PPIs) 或 H2 受体拮抗剂与使用抗凝剂的患者显性上消化道出血的相关性。独立重复审查、数据提取和偏倚风险评估均由两人完成。只有在提供了至少控制了 2 个变量的结果的情况下，才纳入观察性研究。使用随机效应模型进行荟萃分析。
纳入了 6 项观察性研究和 1 项随机试验。除了 1 项研究外，其余所有研究的偏倚风险均较低。没有一项研究排除了同时使用阿司匹林或非甾体抗炎药的患者。对于 PPI，上消化道出血的汇总相对风险为 0.67（95%置信区间 0.61，0.74），具有低统计异质性（I = 15%）。个别研究表明，在上消化道出血风险较高的患者中（例如，使用非甾体抗炎药或阿司匹林、出血风险评分升高），治疗效果更大。一项单独评估 H2 受体拮抗剂与上消化道出血相关性的观察性研究发现，相对风险为 0.69（95%置信区间 0.24-2.02）。
主要来自低偏倚风险的观察性研究的证据表明，PPIs 可减少接受口服抗凝剂治疗的患者的上消化道出血。这种益处在上消化道出血风险升高的患者中最为明显和显著。
