Greater selectivity in GI bleeding prophylaxis needed

Jan 14 2013

Researchers have developed a risk-scoring system to identify noncritically ill hospital patients most likely to benefit from prophylactic acid-suppressive medication.

"Rather than employing a one-size-fits-all approach, our study provides guidance for clinicians in targeting acid-suppressive therapy to those non-ICU-based patients who stand to benefit most, while avoiding the unnecessary cost and risk associated with this therapy in those with extremely low risk of bleeding," say Shoshana Herzig (Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA) and colleagues.

The authors analyzed the medical records of 75,723 non-ICU patients admitted for 3 or more days.

Over 4 years, only 203 patients presented with gastrointestinal bleeding within 24 hours of admission.

The authors identified age over 60 years, male gender, liver disease, acute renal failure, sepsis, the use of anticoagulant medication, pre-existing clotting disorders, and hospitalization within the internal medicine services as independent risk factors for gastrointestinal bleeding.

Using these findings, they created a risk-scoring system using points for patients with these risk factors, totaling a maximum of 18 points.

For patients in the low-medium risk group (8-9 points), the number needed to treat (NNT) with acid-suppressive agents to prevent one case of bleeding was 556. In the high-medium risk group (10-11 points) the number was 159, and in the high-risk group (≥12 points) it was 48. In the low-risk group (≤7 points), the NNT would likely be over 1000 patients, the researchers estimate.

While the use of acid-suppressive medications is routine in the ICU, it is not recommended in non-ICU settings due to a lack of data to support its benefit.

"Moreover, there is growing evidence that these drugs are associated with an increased risk of complications, including hospital-acquired pneumonia and Clostridium difficile," said Herzig in a press statement.

Nevertheless, acid-suppressive medications are used "indiscriminately" in patients who are not critically ill, Herzig noted. Indeed, in this study, 58% of admissions received acid-suppressive medication, and this did not vary according to risk group.

The authors, writing in the Journal of General Internal Medicine, say their risk-scoring system should help physicians prescribe acid-suppressive therapy more selectively but it will need validation in further studies.

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