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Pharmacoeconomic Analysis of Stress Ulcer Prophylaxis for Critically Ill Patients

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Summary

The objective of this study was to evaluate the economic outcomes of drug options for stress ulcer prophylaxis in critically ill and/or intensive care unit patients. Decision analytic modelling was used to compare the costs of stress ulcer prophylaxis and possible clinical outcomes [acute upper gastrointestinal bleeding (AUGB) and nosocomial pneumonia].

The regimens evaluated were: antacids, histamine H2 receptor antagonists (H2RAS), sucralfate and no prophylaxis. The results of published studies were pooled to determine the expected probability of AUGB and nosocomial pneumonia following stress ulcer prophylaxis with each of the agents under study. The costs of stress ulcer prophylaxis, treatment of AUGB and treatment of nosocomial pneumonia were identified from various sources.

Sucralfate was the least costly agent for stress ulcer prophylaxis. The average net costs per patient for sucralfate, antacids, no prophylaxis and H2RAS were $US1457, $US1737, $US2268, and $US2638 to $US2712, respectively (1994 dollars). No prophylaxis was found to be less costly than giving H2RAS. Sucralfate and antacids, which induced net savings of $US7373 and $US4321 per case of AUGB averted, respectively, were more cost effective than H2RAS.

Sensitivity and threshold analyses revealed that the results were constant over a wide range of cost and probability values. Break-even analysis suggested that sucralfate was the optimal agent for stress ulcer prophylaxis unless the acquisition cost of a prophylactic course of sucralfate was >$US304.05 per patient. At that point, antacids become the optimal agent. Based on this analysis, sucralfate may be the most cost-effective agent for stress ulcer prophylaxis in critically ill or intensive care patients.

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References

  1. Kleiman RL, Adair CG, Ephgrave KS. Stress ulcers: current understanding of pathogenesis and prophylaxis. Drug Intell Clin Pharm 1988; 22: 452–60

    PubMed  CAS  Google Scholar 

  2. Schepp W. Stress ulcer prophylaxis: still a valid option in the 1990s? Digestion 1993; 54: 189–99

    Article  PubMed  CAS  Google Scholar 

  3. Cook DJ, Laine LA, Guyatt GH, et al. Nosocomial pneumonia and the role of gastric pH. Chest 1991; 100: 7–13

    Article  PubMed  CAS  Google Scholar 

  4. Cook DJ, Witt LG, Cook RJ, et al. Stress ulcer prophylaxis in the critically ill: a meta-analysis. Am J Med 1991; 91: 519–27

    Article  PubMed  CAS  Google Scholar 

  5. Lacroix J, Infante-Rivard C, Janicek M, et al. Prophylaxis of upper gastrointestinal bleeding in intensive care units: a meta-analysis. Crit Care Med 1989; 17: 862–9

    Article  PubMed  CAS  Google Scholar 

  6. Tryba M. Prophylaxis of stress ulcer bleeding: a meta-analysis. J Clin Gastroenterol 1991; 13 Suppl. 2: S44–55

    Article  PubMed  Google Scholar 

  7. Tryba M. Sucralfate versus antacids or H2-antagonists for stress ulcer prophylaxis: a meta-analysis on efficacy and pneumonia rate. Crit Care Med 1991; 19: 942–9

    Article  PubMed  CAS  Google Scholar 

  8. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994; 330(6): 377–81

    Article  PubMed  CAS  Google Scholar 

  9. Ben-Menachem T, Fogel R, Patel RV, et al. Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. Ann Intern Med 1994; 121: 568–75

    PubMed  CAS  Google Scholar 

  10. Wilcox CM, Spenney JG. Stress ulcer prophylaxis in medical patients: who, what and how much. Am J Gastroenterol 1988; 83(11): 1199–211

    PubMed  CAS  Google Scholar 

  11. Finkler SA. The distinction between costs and charges. Ann Intern Med 1982; 96: 102–9

    CAS  Google Scholar 

  12. Drummond MF, Stoddart GL, Torrance GW. Methods for economic evaluation of health care programmes. Oxford: Oxford University Press, 1990: 41

    Google Scholar 

  13. Basso N, Bagarani M, Materia A, et al. Cimetidine and antacid prophylaxis of acute gastrointestinal bleeding in high risk patients. Am J Surg 1981; 141: 339–41

    Article  PubMed  CAS  Google Scholar 

  14. Cannon LA, Heiselman D, Gardner W, et al. Prophylaxis of upper gastrointestinal tract bleeding in mechanically ventilated patients: a randomized study comparing the efficacy of sucralfate, cimetidine and antacids. Arch Intern Med 1987; 147: 2101–6

    Article  PubMed  CAS  Google Scholar 

  15. Driks MR, Craven DR, Celli BR, et al. Nosocomial pneumonia in intubated patients randomized to sucralfate versus antacids and/or histamine type 2 blockers: the role of gastric colonization. N Engl J Med 1987; 317: 1376–82

    Article  PubMed  CAS  Google Scholar 

  16. Fabian TC, Boucher BA, Croce MA, et al. Pneumonia and stress ulceration in severely injured patients: a prospective evaluation of the effects of stress ulcer prophylaxis. Arch Surg 1993; 1128: 185–92

    Article  Google Scholar 

  17. Friedman CJ, Oblinger MJ, Suratt PM, et al. Prophylaxis of upper gastrointestinal hemorrhage in patients requiring mechanical ventilation. Crit Care Med 1982; 10: 316–9

    PubMed  CAS  Google Scholar 

  18. Garcia-Labattut A, Rodriquez-Munoz S, Gobernado-Serraro M, et al. Sucralfate versus cimetidine in the stress bleeding prophylaxis [abstract]. Intensive Care Med 1990; 16 Suppl. 1: S19

    Google Scholar 

  19. Halloran LG, Zfass AM, Gayle WE, et al. Prevention of acute gastrointestinal complications after severe head injury: a controlled trial of cimetidine prophylaxis. Am J Surg 1980; 139: 44–8

    Article  PubMed  CAS  Google Scholar 

  20. Kappstein I, Schulgen G, Friedman TH, et al. Incidence of pneumonia in mechanically ventilated patients treated with sucralfate or cimetidine as prophylaxis for stress bleeding: bacterial colonization of the stomach. Am J Med 1991; 91 Suppl. 2A: 125S–31S

    Article  PubMed  CAS  Google Scholar 

  21. Khan F, Parekh A, Patel S, et al. Results of gastric neutralization with hourly antacids and cimetidine in 320 intubated patients with respiratory failure. Chest 1981; 79: 409–19

    Article  PubMed  CAS  Google Scholar 

  22. Lacroix J, Infante-Rivard C, Gauthier M, et al. Upper gastrointestinal tract bleeding acquired in a pediatric intensive care unit: prophylaxis trial with cimetidine. J Pediatr 1986; 108: 1015–8

    Article  PubMed  CAS  Google Scholar 

  23. Laggner A, Lenz K, Base W, et al. Prevention of upper gastrointestinal bleeding in long-term ventilated patients. Am J Med 1989; 86: 81–4

    Article  PubMed  CAS  Google Scholar 

  24. Lamothe PH, Rao E, Serra AJ, et al. Comparative efficacy of cimetidine, famotidine, ranitidine and Mylanta in postoperative stress ulcers. Gastroenterology 1991; 100: 1515–20

    PubMed  CAS  Google Scholar 

  25. Luk GD, Summer WR, Messersmith JF, et al. Cimetidine and antacid in prophylaxis of acute gastrointestinal bleeding: a randomized, double-blind, controlled study [abstract]. Gastroenterology 1982; 82: 1121

    Google Scholar 

  26. Macdougall BRD, Bailey RJ, Williams R. H2-receptor antagonists and antacids in the prevention of acute gastrointestinal haemorrhage in fulminant hepatic failure. Lancet 1977; I: 617–9

    Article  Google Scholar 

  27. Martin LF, Booth FVM, Karlstadt RG, et al. Continuous intravenous cimetidine decreases stress-related upper gastrointestinal hemorrhage without promoting pneumonia. Crit Care Med 1993; 21(1): 19–20

    Article  PubMed  CAS  Google Scholar 

  28. Priebe HJ, Skillman JJ, Bushnell LS, et al. Antacid versus cimetidine in preventing acute gastrointestinal bleeding. N Engl J Med 1980; 302: 426–30

    Article  PubMed  CAS  Google Scholar 

  29. Ryan P, Dawson J, Teres D, et al. Nosocomial pneumonia during stress ulcer prophylaxis with cimetidine and sucralfate. Arch Surg 1993; 128: 1353–7

    Article  PubMed  CAS  Google Scholar 

  30. Stotert JC, Siminowitz DA, Dellinger EP, et al. Randomized prospective evaluation of cimetidine and antacid control of gastric pH in the critically ill. Ann Surg 1980; 192: 169–74

    Article  Google Scholar 

  31. Tryba M, Zevounou F, Torok M, et al. Prevention of acute stress bleeding with sucralfate, antacids or cimetidine: a controlled study with pirenzepine as a basic medication. Am J Med 1985; 79 Suppl. 2C: 55–61

    Article  PubMed  CAS  Google Scholar 

  32. Weigelt JA, Aurbakken CM, Gewertz BL, et al. Cimetidine vs antacid in prophylaxis for stress ulceration. Arch Surg 1981; 116: 597–601

    Article  PubMed  CAS  Google Scholar 

  33. Zinner MJ, Zuidema GD, Smith PL, et al. The prevention of upper gastrointestinal tract bleeding in patients in an intensive care unit. Surg Gynecol Obstet 1981; 153: 214–20

    PubMed  CAS  Google Scholar 

  34. Borrero E, Banks S, Margolis I, et al. Comparison of antacid and sucralfate in the prevention of gastrointestinal bleeding in patients who are critically ill. Am J Med 1985; 79 Suppl. 2C: 62–4

    Article  PubMed  CAS  Google Scholar 

  35. Borrero E, Ciervo J, Chang JB. Antacid vs sucralfate in preventing acute gastrointestinal tract bleeding in abdominal aortic surgery. Arch Surg 1986; 121: 810–2

    Article  PubMed  CAS  Google Scholar 

  36. Bresalier RS, Grenell JH, Cello JP, et al. Sucralfate suspension versus titrated antacid for the prevention of acute stress-related gastrointestinal hemorrhage in critically ill patients. Am J Med 1987; 83 Suppl. 3B: 110–6

    Article  PubMed  CAS  Google Scholar 

  37. Hastings PR, Skillman JJ, Bushnell LS, et al. Antacid titration in the prevention of acute gastrointestinal bleeding. N Engl J Med 1978; 298: 1041–5

    Article  PubMed  CAS  Google Scholar 

  38. Israsena S, Anantapanpong S, Kladcharoen N, et al. Sucralfate versus antacid in the prevention of stress ulcer bleeding on mechanical ventilation. J Med Assoc Thai 1987; 70: 678–81

    PubMed  CAS  Google Scholar 

  39. McAlhany JC, Czaja AJ, Pruitt BA. Antacid control of complications of acute gastrointestinal disease after burns. J Trauma 1976; 16: 645–9

    Article  PubMed  Google Scholar 

  40. Mundinger GH, Hays A, Allo M, et al. Effects of meciadanol and sucralfate as compared with antacid titration regimen on prevention of acute gastrointestinal hemorrhage in postoperative intensive care patients. Surg Forum 1985; 121–3

    Google Scholar 

  41. Pinilla JC, Oleniuk FH, Reed D, et al. Does antacid prophylaxis prevent upper gastrointestinal bleeding in critically ill patients? Crit Care Med 1985; 13: 646–50

    Article  PubMed  CAS  Google Scholar 

  42. Tryba M. Side effects of stress bleeding prophylaxis. Am J Med 1987; 85 Suppl. 6A: 85–93

    Google Scholar 

  43. Apte NM, Karnad DP, Medhekar TP, et al. Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial. Crit Care Med 1992; 20: 590–693

    Article  PubMed  CAS  Google Scholar 

  44. Eddleston J, Vohra A, Scott P, et al. A comparison of the frequency of stress ulceration and secondary pneumonia in sucralfate- or ranitidine-treated intensive care unit patients. Crit Care Med 1991; 19: 1491–6

    Article  PubMed  CAS  Google Scholar 

  45. Mahul P, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med 1992; 18: 20–5

    Article  PubMed  CAS  Google Scholar 

  46. 1994 Red Book. Montvale (NJ): Medical Economics Data, Inc., 1994

  47. Copley-Merriam C, Lair TJ. Valuation of medical resource units collected in health economic studies. Clin Ther 1994; 16: 553–68

    Google Scholar 

  48. Babbi E. The practice of social research. 6th ed. Belmont (CA): Woodsworth Publishing Company, 1992: 486

    Google Scholar 

  49. Top 200. Am Druggist 1994 Feb: 27–34

  50. Lam NP, Schumock GT, Winkler S, et al. Pharmacoeconomic evaluation of drug therapy for stress ulcer prophylaxis [abstract]. Gastroenterology 1995; 108(4): A22

    Google Scholar 

  51. L’Abbe KA, Detsky AS, O’Rourke K. Meta-analysis in clinical research. Ann Intern Med 1987; 107: 224–33

    PubMed  Google Scholar 

  52. Cook TD, Campbell ST. Quasi-experimental design & analysis issues for field settings. Boston (MA): Houghtron Miffin Company, 1979: 37–94

    Google Scholar 

  53. Tryba M, Mantey-Stiers F. Antibacterial activity of sucralfate in human gastric juice. Am J Med 1987; 83 Suppl. 3B: 125–7

    Article  PubMed  CAS  Google Scholar 

  54. Prod’horn G, Leuenberger P, Koerfer J, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. Ann Intern Med 1994; 120: 653–62

    Google Scholar 

  55. Cook DJ, Reeve BK, Guyatt GH, et al. Stress ulcer prophylaxis in critically ill patients: resolving discordant meta-analyses. JAMA 1996; 275(4): 308–14

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Pharmacy Services, Wausau Hospital, Wausau, Wisconsin, USA

    Glen T. Schumock

  2. Hospital Pharmacy Services, The University of Illinois Medical Center, Chicago, Illinois, USA

    Nancy P. Lam & Susan R. Winkler

  3. Department of Pharmacy Practice, College of Pharmacy, The University of Illinois at Chicago, Chicago, Illinois, USA

    Nancy P. Lam & Susan R. Winkler

  4. Division of Gastroenterology, College of Medicine, The University of Illinois at Chicago, Chicago, Illinois, USA

    Nancy P. Lam

  5. Department of Pharmacoeconomics, G.D. Searle and Co., Skokie, Illinois, USA

    Sheldon Xiaodong Kong

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  1. Glen T. Schumock
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  3. Susan R. Winkler
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  4. Sheldon Xiaodong Kong
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Schumock, G.T., Lam, N.P., Winkler, S.R. et al. Pharmacoeconomic Analysis of Stress Ulcer Prophylaxis for Critically Ill Patients. Pharmacoeconomics 9, 455–465 (1996). https://doi.org/10.2165/00019053-199609050-00008

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