预防应激性溃疡指南的对比分析及方法学质量评价

Comparative analysis and methodology quality evaluation of stress ulcer prophylaxis guidelines

目的对比国内外预防应激性溃疡指南的异同,并评价各指南的方法学质量。方法检索Pub Med、Embase、Cochrane、Web of Science、CBM、VIP、CNKI、万方,同时检索NGC、GIN和NICE网站,检索期限均为建库至2016年5月。纳入公开发表的预防应激性溃疡相关的临床指南。对比各指南中应激性溃疡的危险因素、推荐药物、停药时机和药物安全性,并分别从收集、分析和形成指南推荐意见三方面评价指南的方法学质量。结果纳入9个指南,均认为预防应激性溃疡应仅限于有高危因素的危重患者,首选药为PPI或H2RA,停药时机尚无高级别推荐意见,预防用药可能增加肺炎等不良事件的风险。在指南方法学方面,9个指南制定过程均无患者代表参与,只有3个指南详细描述了指南制定机构和利益冲突,4个指南列出指南制定团队具体名单;所有指南均未制作新的系统评价,但2个指南引用了足够的系统评价,4个指南的证据强度和推荐意见分级有关联性。结论目前国内外应激性溃疡相关指南整体质量不高,从制作证据到用于推荐意见的指南制定全过程仍有诸多不严谨、有待改进之处。此外,今后制定指南还应纳入目前最新的研究证据(特别是经济学研究)并考虑到预防用药可能带来的不良事件。

Objective To compare the differences of guidelines for stress ulcer prophylaxis（SUP） in and abroad,and evaluate the methodology quality of the guidelines.Methods A search of SUP guidelines was conducted using PubMed,Embase,Cochrane,Web of Science,CBM,VIP,CNKI,Wanfang,NGC,GIN and NICE website（until May 1,2016）,which included published clinical guidelines for SUP.The following was compared：the risk factors of stress ulcer,recommended prevention drugs,safety of drugs,course of treatment,and the method quality was evaluated from gathering,analyzing and linking of evidence to guideline recommendations in current SUP guidelines.Results Nine guidelines were included.It was believed that SUP should be confined to the critical patients with high risk factors.The recommended drugs mainly included proton pump inhibitors（PPI） and H_2-receptor antagonists（H_2RA）.There was insufficient evidence to make any recommendation on course of treatment.SUP might increase the risk of pneumonia and other adverse events.No patient representatives participated in the formulation of guidelines.Only three guidelines were constructed by multi-disciplinary groups where the members＇ affiliations and conflicts of interest were described.Only four guidelines had a specific list of the guideline team.No guideline conducted new systematic reviews to inform recommendations,but two guidelines made extensive use of existing systematic reviews;four guidelines graded the evidence and explicitly linked this to the recommendations.Conclusion The overall quality of SUP guidelines is not high,and there are many points to be improved,f rom the production of evidence to the guidelines for the development of recommendations.In addition,future guidelines should also include the latest research evidence（especially economic research）.The related adverse events of these drugs also need careful consideration.