Evidence
Surveillance decision
We will not update the guideline at this time.
We will amend the guideline to include a footnote to recommendation 1.7.1 for acid-suppression therapy for primary prevention of upper gastrointestinal bleeding in acutely ill patients. This footnote is to make reference to the licensing limitations of H2‑receptor antagonists and proton pump inhibitors for this indication.
Reason for the decision
We found 18 new studies through surveillance of this guideline.
This included new evidence on risk assessment, resuscitation and initial management, management of variceal and non-variceal bleeding and primary prophylaxis for acutely ill patients in critical care. This new evidence was considered to support current recommendations.
We did not find any new evidence on timing of endoscopy, control of bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel, or information and support for patients and carers.
None of the new evidence considered in surveillance of this guideline was thought to have an effect on current recommendations.
The surveillance identified the licensing limitations of H2‑receptor antagonists and proton pump inhibitors for prophylaxis of gastrointestinal bleeding in acutely ill patients. Only the H2-receptor antagonists ranitidine and cimetidine are licensed for this indication. The proton pump inhibitors omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole are not licensed for prophylaxis of gastrointestinal bleeding in acutely ill patients. The use of proton pump inhibitors or H2‑receptor antagonists other than ranitidine and cimetidine for this indication would be off-label.
Additionally, we identified relevant ongoing research that is expected to publish results in the next 3–5 years. The haemorrhage alleviation with tranexamic acid – intestinal system (HALT-IT) trial is assessing the effects of tranexamic acid on mortality, morbidity, blood transfusion, surgical intervention and health status in people with acute gastrointestinal bleeding. In addition, a trial comparing stress ulcer prophylaxis with a proton pump inhibitor versus placebo in critically ill patients (SUP-ICU trial) will consider mortality rates in people at risk of gastrointestinal bleeding. Both trials have planned recruitment completion dates in 2017 and will be considered once results publish.
Other clinical areas
We also found new evidence in areas not covered by the original guideline that was not thought to have an effect on current recommendations. This evidence related to erythromycin for improved endoscopic imaging and tranexamic acid to manage upper gastrointestinal bleeding. However, there is a lack of consistent evidence for erythromycin and tranexamic acid to impact on the guideline at this time.
For any new evidence relating to published or ongoing NICE technology appraisals, the guideline surveillance review deferred to the technology appraisal decision.
Overall decision
After considering all the new evidence, consultation with stakeholders and views of topic experts, we decided that an update is not necessary for this guideline.
See how we made the decision for further information.
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