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Evidenced Based Critically Appraised Topic
Histamine 2 Receptor Blocker versus Proton Pump Inhibitor in Peptic Ulcer Disease
Amanda Lausch BSN, RN, FNP-S
University of Mary
March 8, 2014
Clinical Scenario
A 72 year old female is admitted to a long term care facility temporally for therapy after a right
total hip replacement. She is being started on ibuprofen 600mg orally three times a day as part
of her pain management regimen. She states she has to be cautious with ibuprofen as it upsets
her stomach. She is currently taking clopidogrel and is therefore not a candidate for proton
pump inhibitor therapy (PPI).
Clinical Question
Should histamine 2 receptor blockers (H2RB) be considered as initial treatment in patients for
PUD prophylaxis instead of proton pump inhibitors?
Articles
Alhazzani, W., Alenezi, F., Jaeschke, R., Moayyedi, P., & Cook, D. (2013). Proton pump
inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically
ill patients: A systematic review and meta-analysis. Critical Care Medicine, 41(3), 693705. doi: 10.1097/CCM.0b013e3182758734.
Regidor, R. (2013). Histamine 2 receptor blockers versus proton pump inhibitors part 1: A
literature review. Gastrointestinal Nursing, 11(5), 25-30.
Summary and Appraisal of Key Evidence for Article 1
Regidor, (2013) conducted a Level I, peer-review on the use of H2RB and PPI’s in the
prophylaxis of peptic ulcer disease. Proton pump inhibitors decrease the gastric acid being
secreted more than a H2RB does; 90% versus 30-50% respectively. The effect of a PPI is dose
dependent. While a PPI is more effective at decreasing gastric secretion, they can also adversely
affect patients with various health conditions that were not an issue before. This includes
osteoporosis, Clostridium difficile infection, arrhythmias, and drug interactions. Histamine 2
receptor blockers are selective and do not have a high side effect or drug interaction profile.
While H2RBs have been effective in preventing nighttime acid secretion, they are less effective a
preventing acid secretion during meals. Proton pump inhibitors function best in an acidic
environment. When being used in prophylaxis, the environment may not be acidic already,
therefore the PPI may not be function at its best. Histamine 2 receptor blockers do not require an
acidic environment. Histamine 2 receptor blockers have demonstrated equal effectiveness in
PUD prophylaxis in the acute setting. In this review, H2RBs yielded the same outcomes as PPIs
in the prophylactic treatment of PUD. The results show that PPI’s are more appropriate when
there are active symptoms of dyspepsia or GERD but that H2RB are effective at the prophylaxis
of PUD.
Summary and Appraisal of Key Evidence for Article 2
Alhazzani, Alenezi, Jaeschke, Moayyedi & Cook, (2013) conducted a meta-analysis comparing
PPI’s to H2RBs in the prevention of ulcer bleeding in critically ill patients. This is a Level I,
level of evidence. Fourteen trials with over 1,700 patients were included. Critically ill patients
can develop a gastric ulcer bleed due to stress ulceration. Medication is commonly prescribed to
suppress acid to reduce the risk of ulcer bleeding. Of these fourteen studies, proton pump
inhibitors were shown to be more effective that histamine 2 receptor blockers at reducing upper
gastrointestinal bleeding. This was shown to be a clinically significant statistic. The author
admits the trials were limited by methodology, differences between lower and higher quality
trials, sparse data, and possible publication bias. However, in the critically ill, PPI’s do appear to
be more effective than H2RB in PUD stress ulceration.
Results
The results of the articles indicate that H2RB are not as effective as PPI’s in the prevention of
PUD in the critically ill patient. Additionally, H2RB agents are not as effective as PPI’s in the
prevention of PUD in the patient who has active dyspepsia symptoms or GERD. However, in a
patient who does not have active GI symptoms and is not critically ill, H2RB agents do
demonstrate equal effectiveness in PUD prophylaxis to PPI therapy.
Clinical Bottom Line
Currently, PPI’s are the mostly commonly prescribed therapy for PUD prophylaxis despite their
risk for adverse effects, drug interactions, and cost. It has been proven that H2RBs are as
effective at PUD prophylaxis in those that are not critically ill and do not have active GI
symptoms and should be considered to reduce costs, prevent adverse effects and improve overall
health outcomes.
Implication for practice
I would recommend the use of H2RBs in PUD prophylaxis in patients that are not critically ill
and that do not have active GI symptoms (GERD/dyspepsia). I would continue to follow up with
the patient to reevaluate their need for a H2RB monthly.