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Stress ulcer prophylaxis shows no overall survival benefit in ICU patients but appears to reduce 28-day mortality in specific high-risk groups such as those with malignant cancer, chronic liver disease, coagulopathy, or advanced age.
A large-scale cohort study has highlighted the importance of tailoring stress ulcer prophylaxis (SUP) to individual risk profiles in critically ill patients. While SUP is commonly utilized in intensive care units (ICUs) to prevent gastrointestinal bleeding, its overall potency has been questioned. In this study, researchers investigated whether certain subgroups of ICU patients might benefit more than others, revealing significant heterogeneity in treatment effects.
The study analyzed data from 25,475 ICU patients who had at least 1 risk factor for clinically important gastrointestinal bleeding. Among them, 6,199 patients (24.3%) received SUP within 48 hours of ICU admission, with famotidine being the most frequently prescribed agent (53.7%). Using statistical techniques to balance baseline characteristics between treatment groups, the authors found no vital difference in 28-day mortality between patients who received SUP and those who did not. The overall adjusted odds ratio (OR) for mortality was 1.03, suggesting no clear survival benefit from routine SUP use.
However, when researchers explored the data through conventional subgroup, risk-based, and effect-based analyses, notable differences emerged. The impact of SUP varied markedly based on patient characteristics. For example, patients aged 77 years or older exhibited a markedly different response when compared to younger patients, with a posterior probability of treatment effect difference of 99.3%. Similarly, those with chronic liver disease (99.9%), coagulopathy (92.1%), or malignant cancer (100%) illustrated a higher likelihood of benefit from SUP.
As per risk-based analysis, those with a higher baseline risk of death were more likely to benefit, though the probability remained modest (posterior probability of OR > 1: 1.9%). Effect-based analysis further identified individuals with malignant cancer and higher Charlson comorbidity scores as having the strongest potential for improved outcomes with SUP. Hence, while SUP may not yield a mortality benefit across the general ICU population, its use appears to be more advantageous in specific high-risk groups.
Patients with chronic liver disease, coagulopathy, malignant cancer, or advanced age may derive meaningful benefit from early SUP initiation. These findings suggest that a more individualized approach to SUP could boost patient outcomes while minimizing unnecessary intervention in lower-risk individuals.
BMC Medicine
Heterogeneous treatment effects of stress ulcer prophylaxis among ICU patients at risk for gastrointestinal bleeding
Yongpeng Xie et al.
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