PPIs for prevention of gastrointestinal bleeding: A systematic review of evidence

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Created On: 09/01/2025

This study sought to evaluate the safety and efficiency of proton-pump inhibitors (PPIs) for stress ulcer prevention in severely ill individuals.

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Key take away

In critically ill patients with stress ulcer, proton-pump inhibitors reduce upper gastrointestinal bleeding but may have varying effects on mortality depending on disease severity.

Background

This study sought to evaluate the safety and efficiency of proton-pump inhibitors (PPIs) for stress ulcer prevention in severely ill individuals.

Method

In this systematic review and meta-analysis, randomized trials comparing PPIs with placebo or no prophylaxis in severely ill adults were incorporated. Meta-analyses were carried out. With the aid of the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE), evidence certainty was examined. The subgroup assessment explored the impact of PPIs on mortality on the basis of illness severity. It combined subgroup data from the 2 largest studies. Determination of credibility was done via the Instrument for Assessing the Credibility of Effect Modification Analyses.

Result

Overall, 12 trials involving 9,533 patients were incorporated. PPIs were linked with a remarkable drop in upper gastrointestinal bleeding (relative risk [RR], 0.51; 95% confidence interval [CI], 0.34–0.76; high-certainty evidence). PPIs likely have minimal or no impact on mortality (RR, 0.99; 95% CI, 0.93–1.05; low certainty).

Subgroup analysis, deemed moderately credible, illustrated mortality effects might vary by disease severity. Specifically, PPIs could diminish 90-day mortality in those with moderate illness (RR, 0.89; 95% CI, 0.80–0.98) while potentially escalating it in those with severe illness (RR, 1.08; 95% CI, 0.96–1.20). PPIs likely do not influence the risk of pneumonia. They also have minimal or no impact on Clostridioides difficile infection, with low certainty.

Conclusion

High-certainty evidence supports PPIs' role in minimizing upper gastrointestinal bleeding in critically ill individuals. While PPIs exhibit little to no overall impact on mortality, potential differences in outcomes based on disease severity warrant further investigation.