Just when you thought it was all over !

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Just when you thought it was all over !

This Meta-analysis suggests that ranitidine is ineffective in the prevention of GI bleeding and might increase the incidence of pneumonia. Studies on Sucralfate do not provide conclusive results. However these conclusions are based on a few small trials are must be interpreted carefully.

Level of Evidence 1^-

Citation/s:
Messori A, Troppoli S, Gorini M, Corrado A. Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials. BMJ 2000;321:1-7

Lead author's name and fax: A Messori md3439@mclink.it

Three-part Clinical Question: Are sucralfate and ranitidine equally effective in the prevention of clinically significant upper GI haemorrhage in the ventilated intensive care patient. Is there a difference in the rates of VAP when the two treatments are compared.

Search Terms: Stress, pneumonia, ranitidine, sucralfate, RCT

The Review:

Data Sources: : Medline, Iowa-IDIS database, Drugdex

Study Selection: RCTs, English. Intensive care patients, ventilated, assessment of GI bleeding. Definition of clinically significant bleeding as in the Meta-analysis by Cook.

Data Extraction: Intensive care patients

The studies were not multiple independent reviews of individual reports. They were tested for heterogeneity.

The Evidence:
Outcome Time to Outcome Typical CER Typical OR RRR NNT p Value

Bleeding. Ranitidine vs placebo (5 trials, 3 included by Cook)
ICU discharge 0.02 0.72 28% 181 0.46
95% Confidence Intervals: .3 to 1.7 72 to -74
Bleeding: Sucralfate vs placebo (only one study, included by Cook) ICU discharge 0.02 1.26 -25% -197 0.7
95% Confidence Intervals: 0.12 to 12.9 57 to -5

Pneumonia: Ranitidine vs placebo (3 trials, 2 included by Cook)
ICU discharge 0.2 0.98 2% 311 0.94
95% Confidence Intervals: 0.56 to 1.72 13 to -10

Pneumonia: Sucralfate vs Placebo (2 trials, both in Cook)
ICU discharge .2 2.21 -78% -6 0.1
95% Confidence Intervals: 0.86 to 5.65 43 to -3
Pneumonia: Ranitidine vs Sucralfate (8 trials, 5 included by Cook) ICU discharge .2 1.35 -26% -19

0.012
95% Confidence Intervals: 1.07 to 1.7 -91 to -10

Comments:
This study attempt to firstly, provide an up-to-date meta-analysis in the face of changing practice and secondly fill some of the gaps in the Cook review. Its conclusions differ. Why? Practise has changed. Ranitidine having replaced cimetidine as the sole H2 blocker. Enteral feeding is more common.
Care must be taken in interpreting these results. They are based on e few small trials in very different and sometimes specific groups of patients (Burns, Head injury, Trauma).

Appraised by: Dr Chris Cairns, Spr in Anaesthetics & Intensive Care, Edinburgh Royal Infirmary.; Monday, December 23, 2002
Email: Chris.Cairns@btinternet.com
Kill or Update By: Dec 2007

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