Hda Ibp vs Antih2

8/11/2019 Hda Ibp vs Antih2

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Manejo de HDA no varicon inhibidores de lasecrecin cida - Qu

dice la evidencia?


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Proton pump inhibitors versus H2-antagonists: a meta-anaefficacy in treating bleeding peptic ulcer.Gisbert JP1, Gonzlez L, Calvet X, Roqu M, Gabriel R, PajAliment Pharmacol Ther 2001.

STUDY SELECTION:

Comparative randomized trials of proton pump inhibitors (omeprazole, lansoprazole, or pantoprazoranitidine or famotidine).

DATA SYNTHESIS:

Eleven studies fulfilled the inclusion criteria and contained data for at least one of the planned comrecurrent bleedingwas reported in 6.7% (95% CI : 4.9-8.6%) of the patients treated with proton pump(95% CI: 10.8-16%) of those treated with H2-A (OR 0.4; 95% CI: 0.27-0.59) (chi2-homogeneity test, 18; neededin 5.2% (95% CI: 3.4-6.9%) of the patients treated with proton pump inhibitors, and in 6.9% (95patients treated with H2-A (OR 0.7; 95% CI: 0.43-1.13). Respective percentages for mortalitywere 1.62.2% (95% CI: 1.3-3.7%) (OR 0.69; 95% CI: 0.31-1.57).

SUB-ANALYSIS: Five studies evaluated the effect of both therapies given in bolus injections on persist

rate, which was 6% (95% CI: 3.6-8.3%) and 8.1% (95% CI: 5.3-10.9%), respectively (OR, 0.57; 95% CI: 0.3recurrent bleeding in high risk patients (Forrest Ia, Ib and IIa) occurred in 13.2% (95% CI: 7.9-8%) of theproton pump inhibitors and in 34.5% (27-42%) of those treated with H2-A (OR 0.28; 95% CI: 0.16-0.48).endoscopic therapy, persistent or recurrent bleeding was reported, respectively, in 4.3% (95% CI: 2.78.7-15%) (OR 0.24; 95% CI: 0.13-0.43). Less marked differences were observed in patients having adju10.3% (95% CI: 6.7-13.8%) and 15.2% (11.1-19.3%) (OR 0.59; 95% CI : 0.36-0.97). Moreover, the significagroup when a single outlier study was excluded.

CONCLUSIONS:

Proton pump inhibitors are more effective than H2-A in preventing persistent or recurrent bleeding frthis advantage seems to be more evident in patients not having adjunct sclerosis therapy. This benesimilar or even more marked in patients with Forrest Ia, Ib or IIa ulcers. However, proton pump inhibitthan H2-A for reducing surgery or mortality rates. Nevertheless, the data are too scarce and heterogconclusions, and further comparative trials are clearly warranted.


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Meta-analysis: the efficacy of intravenous H2-receptor anbleeding peptic ulcer.Levine JE1, Leontiadis GI, Sharma VK, Howden CW. AlimenTher. 2002

BACKGROUND:

Although a previous meta-analysis found that intravenous H2-receptor antagonists were only weakly beneficiand of no benefit in bleeding duodenal ulcer, patients with ulcer bleeding continue to receive such treatmen

AIM:

To re-evaluate the efficacy of intravenous H2-receptor antagonists in ulcer re-bleeding, surgery and mortality meta-analysis.

METHODS:

After two independent literature searches, randomized, placebo-controlled trials of intravenous H2-receptor aulcer published between 1984 and 2000 were added to those from the initial meta-analysis. Pooled rates of redeath were re-calculated, together with the relative risk reduction, absolute risk reduction, number needed toHaenszel odds ratio.

RESULTS:

Intravenous H2-receptor antagonists did not significantly reduce re-bleeding, surgery or death in bleeding dusmall but significant reductions in re-bleeding, surgery and death in bleeding gastric ulcer; the absolute risk reand 3.2%, respectively.

CONCLUSIONS:

Intravenous H2-receptor antagonists are of no value in bleeding duodenal ulcer, although they may be mildlygastric ulcer. Because proton pump inhibitors have a greater inhibitory effect on gastric acid secretion than Hthey may be more effective in ulcer bleeding and should be further evaluated for that indication.


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lcergstric

lceraduodenal


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lceragstrica +duodenal


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Systematic reviews of the clinical effectiveness and cost-eof proton pump inhibitors in acute upper gastrointestinal bGI Leontiadis, A Sreedharan, S Dorward, P Barton, B DelanHowden, M Orhewere, J Gisbert, VK Sharma, A Rostom, P

and D Forman. Health Technology Assessment 2007; Vol. 1 Methods For the first objective, evidence was sought with the Cochrane Collaboration m

two systematic literature reviews of randomised controlled trials (RCTs) on the ceffectiveness of oral or intravenous PPI treatment in patients with acute UGI blereview concerned PPI use in patients with an endoscopic diagnosis of PU; trialssearching CENTRAL, the Cochrane Library, MEDLINE, EMBASE and major confeup to November 2004. The second review concerned oral or intravenous PPI uendoscopy in patients with UGI bleeding; trials were identified by searching CECochrane Library, MEDLINE, EMBASE, CINAHL and major conference proceediSeptember 2005.

Results

PPI treatment initiated after endoscopic diagnosis of PU bleeding significantly bleeding [odds ratio (OR) 0.49, 95% confidence interval (CI) 0.37 to 0.65; numb(NNT) 13, 95% CI 9 to 25] and surgery (OR 0.61, 95% CI 0.48 to 0.78; NNT 33, 95% compared with placebo or H2RA. There was no evidence of an overall effect all-cause mortality (OR 1.01, 95% CI 0.74 to 1.40). However, PPIs significantly redsubgroups when studies conducted in Asia were examined in isolation (OR 0.350.74) or when the analysis was confined to patients with high-risk endoscopic fibleeding, oozing of blood or a non-bleeding visible vessel) (OR 0.53, 95% CI 0.3

PPI treatment initiated prior to endoscopy in UGI bleeding significantly reducedpatients with stigmata of recent haemorrhage (SRH) at index endoscopy complacebo or H2RA (OR 0.67, 95% CI 0.54 to 0.84; NNT 11, 95% CI 7 to 25). Howeveevidence that PPI treatment affected clinically important outcomes, namely mbleeding or need for surgery.


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International Consensus Recommendations on the ManagPatients With Nonvariceal Upper Gastrointestinal BleedingMed. 2010;

Statement C3

An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding andstigmata who have undergone successful endoscopic therapy.

(Agree, 94% [Vote: a, 65%; b, 24%; c, 6%; d, 3%; e, 0%; f, 3%]. Grade: High, 1a, do it)

A 2006 Cochrane meta-analysis of data as of November 2004 (124) included 24 RCTs and was updated (24) w(Appendix Table 2). The updated meta-analysis included 5792 patients. Overall, PPI therapy with or without enrebleeding (OR, 0.45 [CI, 0.36 to 0.57]) and surgery (OR, 0.56 [CI, 0.45 to 0.70]) but not mortality (OR, 0.90 [CI, 0or histamine-2 receptor agonist. Proton-pump inhibitor therapy reduced mortality among patients with activeconducted in Asia. Further analysis showed that in patients with active bleeding or NBVV who received endosintravenous PPI therapy (80 mg bolus plus 8 mg/h continuous infusion) reduced rebleeding (OR, 0.43 [CI, 0.27 0.96]), and mortality (OR, 0.57 [CI, 0.34 to 0.96]). Lower doses of PPI (either intravenous or oral) reduced rebleean effect on mortality.

Similarly, the meta-analysis by Laine and McQuaid (99) found significant benefit in rebleeding (RR, 0.40 [CI, 0.2

to 0.58]), and mortality (RR, 0.41 [CI, 0.20 to 0.84]) with high-dose intravenous PPI therapy after endoscopic theassociated with significant benefits in rebleeding (RR, 0.53 [CI, 0.35 to 0.78]) but not surgery or mortality compa

Strong evidence demonstrates the efficacy of high-dose intravenous PPI therapy after successful endoscopy,conclusions regarding the efficacy of either lower intravenous doses or high-dose oral therapy. Indeed, head-analyses of high versus lower intravenous doses are underpowered, and no direct comparisons of high-dose ioral therapy have been made. However, lower intravenous doses or high-dose oral PPI therapy (at doses equdaily oral dose) are also effective (especially in Asian populations) and can be considered when high-dose infeasible.

In patients with UGIB who have undergone successful endoscopic hemostasis, administering high-dose intravemore effective and less costly than not doing so, as demonstrated by cost analyses (132134)or can becomanalyses (83, 122). The intervention group usually receives high-dose intravenous PPI therapy, and the compafew trials have included low-dose intravenous or oral PPI as comparators. High-dose intravenous PPI therapy isthe cost of the medications is relatively lower than the incremental expenses of 1 additional rebleeding episodoral PPI use remain theoretical, because only a few underpowered RCTs (135137) have assessed this compar

Although recent data have linked PPI use to in-hospital Clostridium difficile infection (138139), the participantrisks in patients who have acute UGIB that requires PPI therapy.


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Proton pump inhibitor treatment initiated prior to endoscoin upper gastrointestinal bleeding.Sreedharan A1, Martin J, Leontiadis GI, Dorward S, HowdeForman D, Moayyedi P. Cochrane Database Syst Rev. 201

Objectives To systematically review evidence from randomised controlled tr

treatment initiated before endoscopy for upper gastrointestinal b

Search methods

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASdatabases and major conference proceedings to September 20Cochrane Upper Gastrointestinal and Pancreatic Diseases modewere re-run in February 2006 and October 2008.

Selection criteria We selected randomised controlled trials (RCTs), of hospitalised p

unselected upper gastrointestinal bleeding, undergoing active trproton pump inhibitor PPI (oral or intravenous) and control treatmplacebo, histamine-2 receptor antagonist (H2RA) or no treatmenendoscopy.


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Main results Six RCTs comprising 2223 participants were included. There was no statistical he

among trials for dichotomous outcomes. There were no statistically significant dmortality, rebleeding or surgery between PPI and control treatment. Unweightrates were 6.1% and 5.5% respectively (odds ratio (OR)1.12; 95% CI 0.72 to 1.73pooled rebleeding rates were 13.9% and 16.6% respectively (OR 0.81; 95%CI 0.rates for surgery were 9.9% and 10.2% respectively (OR 0.96 95% CI 0.68 to 1.35)compared to control significantly reduced the proportion of participants with Sendoscopy; unweighted pooled rates were 37.2% and 46.5% respectively (OR 0.84). However, this result was not robust to sensitivity analysis. PPI treatment cosignificantly reduced endoscopic therapy at index endoscopy; unweighted po

8.6% and 11.7% respectively (OR 0.68; 95% CI 0.50 to 0.93). For continuous outchospital stay and blood transfusion requirements), quantitative analysis could n

Authors' conclusions

PPI treatment initiated before endoscopy for upper gastrointestinal bleeding mproportion of participants with SRH at index endoscopy and significantly reducendoscopic therapy during index endoscopy. However, there is no evidence taffects clinically important outcomes, namely mortality, rebleeding or need fo


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State-of-the-Art Management of Acute Bleeding Peptic UHisham Al Dhahab, Julia McNabb-Baltar,1 Talal Al-TaweelBarkun. Saudi J Gastroenterol. 2013 Sep-Oct

Proton pump inhibitors prior to endoscopy

Proton pump inhibitors (PPIs) play an important role in the stabilization of cresponse to bleeding peptic ulcers through pH-dependent factors, by raiperhaps helping optimize platelet aggregation.[27] Raising the pH may apepsin-mediated clot lysis and fibrinolytic activity. A Cochrane systematicmeta-analysis of six RCTs, including 2223 patients comparing PPI with conadministrations [placebo or histamine-2 (H2)-receptor antagonists] foundpre-endoscopic administration of PPIs led to a reduction in the most impo

outcomes following AUGIB, namely, rebleeding, mortality, or need for surgHowever, the use of pre-endoscopic PPI may delay the need for endoscoby downstaging high-risk endoscopic ulcer lesions into low risk. This may pwhen early endoscopy is not feasible or local expertise is limited, the use oendoscopic PPI, however, should not replace appropriate initial resuscitaperformance of early endoscopy.[29]


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Patients bleeding who are using aspirin (ASA) and/or clopidogrel

Low-dose ASA (325 mg/d) is of definite and substantial benefit for the prvascular disease. In a large meta-analysis from the UK by the AntithromboCollaboration, ASA use in patients with established occlusive vascular diseabsolute reduction in vascular events per year (6.7% vs. 8.2% per year, P

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