• 
• 

Three Part Question

In critical ill patients managed on an Intensive Care Unit, IS [Rantidine] better than [Proton Pump Inhibitors] AT[preventing gastric stress ulcers]?

Clinical Scenario

A 29 yr old male is admitted to the ICU following a significant head injury sustained in a road traffic accident. He is being managed in accordance with head injury guidleines but in addition he is prescribed Omeprazole 20 mg i.v od, for gastric ulcer prophylaxis. This is changed to Ranitidine 50 mg i.v tds, two days later on the advice of the pharmacist, the indication remaining the same.
You wonder if there is any difference in benefit between the two drugs for the prevention of gastric stress ulcers.

Search Strategy

MEDLINE 1966 to November Week 3 2006
using OVID interface
[ranitidine.mp. or exp Ranitidine/ or Zantac.mp] AND [Omeprazole.mp. or exp Omeprazole/ or exp Omeprazole/ or lansoprazole.mp. or exp Proton Pumps/ or PPIs.mp or PPI.mp or Proton Pump Inhibitor.mp] AND [intensive care.mp. or exp Intensive Care/ or exp Critical Care/ or exp Intensive Care Units/ or ITU.mp. or exp Intensive Care/ or exp Critical Illness/ or ICU.mp] limits Human and English

Search Outcome

13 articles were found, 1 was relevant to the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Levy, M J. Seelig, C B. Robinson, N J. Ranney, J E. 1997 Jun. North Carolina, USA	67 high risk ICU patients randomised to receive Ranitidine (N = 35) 150 mg intravenously daily or Omeprazole (N = 32) 40 mg daily orally or by nasogastric route	This was a prospective, randomized clinical trial.	Clinically Important Bleeding	11/35 i.e 31% with Ranitide v/s 2/32 i.e 6% iwith Omeprazole (p<0.05)	A significant difference was found in regard to the number of risk factors per patient. The ranitidine-treated group had 2.7 risk factors per patient while the omeprazole-treated group had 1.9 (P < 0.05). Therefore the patinets treated with Ranitidine were naturally at higher risk to develop complications.
			Nosocomial Pneumonia, secondary outcome measure	5/35 i.e 14% with Ranitidine 1/32 i.e 3% with Omeprazole (p> 0.05)

Comment(s)

Patients admitted to intensive care units are routinely administered antacids, sucralfate, histamine-2 (H2)-receptor antagonists, or proton-pump inhibitor, to prevent stress ulcer development. However not much data comparing the various protocols and attempting to demonstrate differences among them are available and different prescribing protocols are followed.

Editor Comment

There have been some studies demonstrating the positive immunomodulatory effect of Ranitidine on T lymphocytes, whcih are diminuted in the delayed hypersensitivity reaction seen in trauma and cancer patients, whcih in turn, may be responsible for the stress ulcer formation in these patients. However, it is still uncertain whether this positive immunomodulation by Ranitidine will result in a decreased rate of formation or increased rate of cure of the stress ulcer?

Clinical Bottom Line

There is no srong evidence suggesting which anti-ulcer regime is prefered. Local protocols and policies should be used as a guide in the management of these patients

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Levy, M J. Seelig, C B. Robinson, N J. Ranney, J E. Comparison of omeprazole and ranitidine for stress ulcer prophylaxis Digestive Diseases & Sciences. 42(6):1255-9, 1997 Jun.