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The effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in critically ill adults: a systematic review with meta-analysis

  • Ethan Butler
  • Morten Hylander Møller
  • Oliver Cook
  • Anders Granholm
  • James Penketh
  • Sofie Louise Rygård
  • Anders Aneman
  • Anders PernerEmail author
Systematic Review

Abstract

Purpose

To assess the effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in adult critically ill patients.

Methods

We systematically reviewed randomised clinical trials comparing systemic corticosteroids administered for more than 24 h with placebo/no treatment in adult critically ill patients. Trial selection, data abstraction and risk of bias assessments were performed in duplicate. We used trial sequential analysis (TSA) to assess the risk of random errors and the grading of recommendations, assessment, development, and evaluations (GRADE) approach to assess the quality of evidence. The primary outcome was the incidence of clinically important gastrointestinal bleeding within 90 days. The secondary outcome was the incidence of gastrointestinal bleeding of any severity within 90 days.

Results

Twenty-five trials (n = 14,615) reported data for the primary outcome and 55 trials (n = 21,792) for the secondary outcome. The pooled incidence of clinically important gastrointestinal bleeding was 2.3% in the corticosteroid group and 1.8% in the control group (RR, 1.26; 95% CI, 1.01–1.57; I2 = 0%, TSA-adjusted CI 0.51–3.14). We observed no difference in the risk of gastrointestinal bleeding of any severity (RR, 1.10; 95% CI, 0.92–1.32; I2 = 0%, TSA-adjusted CI 0.87–1.38). The GRADE quality of evidence was low (risk of bias and imprecision).

Conclusions

We observed an overall low incidence of clinically important gastrointestinal bleeding among adult critically ill patients. Corticosteroids may slightly increase the incidence of clinically important gastrointestinal bleeding, but not bleeding of any severity. Rarity of events, infrequent trial reporting and high risk of bias reduced the quality of evidence.

Keywords

Gastrointestinal bleeding Peptic ulcer disease Corticosteroids Steroids Critical illness Intensive care unit Systematic review 

Notes

Acknowledgements

We are indebted to the numerous authors who have provided additional information and clarifications regarding their studies including Professors Ananne, Arabi, Ashenoune, Briegel, Christ-Crain, Chotmongkol, Cicarelli, Day, Edwards, Gordon, Hoffman, Keh, Kerr, Martin Jr, Meduri, Mirea, Paydas, Payen, Sawanyawisuth, Scarborough, Sorensen, Sprung, Thwaites, Venkatesh and Weigelt and Dr’s Alía, Blum, Fernandez-Serrano and Plassais. We are also grateful for the assistance with translations of non-English studies from Mr Chris Chui, Dr Peter Biesenbach and Dr Fernando Zampieri. We apologise if in the process of transcribing we have accidently left out authors who have aided this study and we offer our utmost gratitude. .

Funding

No funding was received for any aspect of this study.

Compliance with ethical standards

Conflicts of interest

EB, MHM, OC, AG, JP, SLR, AA: none to declare. AP: the ICU at Rigshospitalet, where AP chairs the Research Unit, receives funds for research from Ferring Pharmaceuticals and the Novo Nordisk Foundation.

Supplementary material

134_2019_5754_MOESM1_ESM.doc (2.9 mb)
Supplementary material 1 (DOC 2974 kb)

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Royal North Shore HospitalSt LeonardsAustralia
  2. 2.Intensive Care UnitLiverpool HospitalSydneyAustralia
  3. 3.South Western Sydney Clinical SchoolUniversity of New South WalesSydneyAustralia
  4. 4.Ingham Institute for Applied Medical ResearchSydneyAustralia
  5. 5.Department of Intensive Care, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
  6. 6.Centre for Research in Intensive Care, RigshospitaletUniversity of CopenhagenCopenhagenDenmark

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