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JAMA:ICU中质子泵抑制剂预防应激性溃疡有效吗?

2020-03-24 杨中华 脑血管病及重症文献导读

2020年2月来自新西兰的aul J.Young等在 JAMA 上公布了PEPTIC试验结果,目的在于验讫在 ICU 中使用质子泵抑制剂(PPI)和使用 H-2受体阻滞剂(H2RB)对在院死亡率的作用

2013年和2014年收集的数据表明,在入住 ICU 的急性成人患者中,估计有2.5%的患者出现了上消化道出血,为了预防这种出血,70%的患者接受了预防应激性溃疡的药物。尽管报道质子泵抑制剂能够降低出血的风险,2014年的数据显示其是最常处方的药物,但是有些医生还是处方了 H-2 受体阻滞剂。这种临床上的差异主要取决于临床医生的偏好或医院政策。一项随机临床试验的 meta 分析得出结论,质子泵抑制剂在预防上消化道出血方面可能比 H-2受体阻滞剂更加有效;然而,这一结论受到有效数据缺乏的限制,以及试验方法学的限制,以及可能存在发表偏倚。

与使用 H-2受体阻滞剂相比,使用质子泵抑制剂与医院内肺炎和难辨梭状芽孢杆菌感染的风险增加有关。据报道,质子泵抑制剂具有免疫抑制作用,可能会增加 ICU 患者常见感染相关并发症的死亡风险。这些免疫抑制作用,包括抑制自然杀伤细胞活性、中性粒细胞趋化和超氧化物产生。不同种类的预防应激性溃疡的药物对死亡率的影响尚不清楚,因为尚无效力充分的 ICU 患者临床试验数据,包括比较质子泵抑制剂和 H-2受体阻滞剂的试验。

2020年2月来自新西兰的aul J.Young等在 JAMA 上公布了PEPTIC试验结果,目的在于验讫在 ICU 中使用质子泵抑制剂(PPI)和使用 H-2受体阻滞剂(H2RB)对在院死亡率的作用。

该研究为簇交叉随机临床试验,纳入的患者为入住 ICU 24h 内需要有创机械通气的患者,随访90天。比较了两种预防应激性溃疡的策略(优先使用 PPI vs 优先使用 H2RB),共50家 ICU 参与。每个 ICU 连续使用随机的治疗药物6个月;25家 ICU 随机按顺序使用 PPI,然后使用 H2RB,25家 ICU 随机按顺序使用 H2RB,然后使用 PPI(译者注:每个 ICU 使用其中一种治疗药物半年,然后该 ICU 换为另一种治疗药物半年)(13436例根据所在 ICU 随机接受了 PPI,13392例接受了 H2RB)。主要终点为90天内全因死亡。次要终点为临床重要的上消化道出血,难辨梭状芽孢杆菌感染,ICU 及医院的住院时长。

最终26828例纳入分析。PPI 组和 H2RB 组90天在院死亡率分别为18.3%和17.5% (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)。随机接受 PPI 治疗的患者中估计4.1%接受了 H2RB 治疗,随机接受 H2RB 治疗的患者中估计20.1%接受了 PPI 治疗。PPI 组和 H2RB 组临床重要上消化道出血的比率分别为1.3%和1.8%(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)。两组难辨梭菌感染和 ICU、医院住院时间没有差异。

最终作者认为对于需要机械通气的 ICU 患者,PPI 和 H2RB 预防应激性溃疡策略的在院死亡率分别为18.3%和17.5%,差异未达到显着性。不过,该研究结果可能受到指定药物交叉的限制。

原始出处:PEPTIC Investigators for the Australian and New Zealand Intensive Care Society Clinical Trials Group, Alberta Health Services Critical Care Strategic Clinical Network, and the Irish Critical Care Trials Group, et al. 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. JAMA. 2020 Jan 17.

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    2021-01-22 jklm09
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    2020-03-24 旺医

    顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息

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