Sangrado gastrointestinal en pacientes hospitalizados
Gastrointestinal bleeding in hospitalized patients
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Diaztagle F., J. J., Cruz B., R. H., Eslava O., D. F., Briceño P., J. F., Hernández A., A. C., Jiménez M., N., Jiménez M., M., Melo F., L. C., Sierra M., R. E., & Vásquez H., L. (2014). Sangrado gastrointestinal en pacientes hospitalizados. Revista Repertorio De Medicina Y Cirugía, 23(1), 9–17. https://doi.org/10.31260/RepertMedCir.v23.n1.2014.736
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El sangrado gastrointestinal es una complicación potencial del paciente que se hospitaliza. Como las descripciones iniciales en cuidados intensivos relacionaban el sangrado por úlceras de estrés con alta mortalidad, la investigación fue creciente en los pacientes críticos. No sucedió lo mismo con los hospitalizados y los trabajos disponibles son escasos. Los principales factores de riesgo se han descrito en los críticos (ventilación mecánica más de 48 horas y coagulopatía). La eficacia de la terapia no se ha demostrado en aquellos en la sala general. La evidencia indirecta muestra utilidad marginal de estos medicamentos en la prevención del sangrado gastrointestinal. En los casos críticos hay abundante información pero la interpretación es confusa. Se ha documentado una tasa alta de formulación para prevenir el sangrado en los hospitalizados, la mayoría sin indicación clara, lo cual puede exponer al paciente a eventos adversos innecesarios y gastos adicionales al sistema de salud. Se recomiendan estrategias para implementación de guías para el uso racional de estos fármacos. Abreviaturas: SGI, sangrado gastrointestinal; SRMD, stress-related mucosal disease; AINES, antiinflamatorios no esteroideos; ASHP, American Society of Health-System Pharmacists; FDA, Food and Drug Ad- ministration; ERGE, enfermedad por reflujo gastroesofágico.
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1. Marik P, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new millenium: A systematic review and meta-analysis. Crit Care Med. 2010; 38:2222-28.
2. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm. 2007 Jul 1; 64(13):1396-400.
3. Fennerty MB. Pathophysiology of the upper gastrointestinal tract in the critically ill patient: rationale for the therapeutic benefits of acid suppression. Crit Care Med. 2002 Jun; 30(6 Suppl):S351-5.
4. Mutlu GM, Mutlu EA, Factor P. GI complications in patients receiving mechanical ventilation. Chest. 2001;119(4):1222-41.
5. Metz DC. Preventing the gastrointestinal consequences of stress-related mucosal disease. Curr Med Res Opin. 2005 Jan; 21(1):11-8.
6. Quenot JP, Thiery N, Barbar S. When should stress ulcer prophylaxis be used in the ICU?. Curr Opin Crit Care. 2009; 15:139-43.
7. Amaral MC, Favas C, Alves JD, Riso N, Riscado MV. Stress-related mucosal disease: Incidence of bleeding and the role of omeprazole in its prophylaxis. Eur J Int Med. 2010; 21(5):386-88.
8. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006 Jan; 1(1):13-20.
9. Herzig SJ, Vaughn BP, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for nosocomial gastrointestinal tract bleeding. Arch Intern Med. 2011 Jun 13; 171(11):991-7.
10. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994 Feb 10; 330(6):377-81.
11. Cook D, Heyland D, Griffith L, Cook R, Marshall J, Pagliarello J. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. Crit Care Med. 1999 Dec; 27(12):2812-7.
12. Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002 Jun; 30 (6 Suppl):S362-4.
13. Stollman N, Metz DC. Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care. 2005 Mar; 20(1):35-45.
14. Martindale RG. Contemporary strategies for the prevention of stress-related mucosal bleeding. Am J Health Syst Pharm. 2005 May 15; 62(10 Suppl 2):S11-7.
15. Terdiman JP, Ostroff JW. Gastrointestinal bleeding in the hospitalized patient: a case-control study to assess risk factors, causes, and outcome. Am J Med. 1998 Apr; 104(4):349-54.
16. Estruch R, Pedrol E, Castells A, Masanes F, Marrades RM, Urbano-Marquez A. Prophylaxis of gastrointestinal tract bleeding with magaldrate in patients admitted to a general hospital ward. Scand J Gastroenterol. 1991 Aug; 26(8):819-26.
17. Grau JM, Casademont J, Fernandez-Sola J, Cardellach F, Urbano-Marquez A. Prophylaxis of gastrointestinal tract bleeding in patients admitted to a general hospital ward. Comparative study of sucralfate and cimetidine. Scand J Gastroenterol. 1993 Mar; 28(3):244-8.
18. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999 Feb 15; 56(4):347-79.
19. Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med. 1998 Mar 19; 338(12):791-7.
20. Conrad SA, Gabrielli A, Margolis B, Quartin A, Hata JS, Frank WO, et al. Randomized, double blind comparison of immediate-release omeprazole-oral suspension versus intravenous cimetidina for prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med. 2005; 33(4):760-65.
21. Cook DJ, Witt LG, Cook RJ, Guyatt GH. Stress ulcer prophylaxis in the critically ill. A meta-analysis. Am J Med. 1991 Nov; 91(5):519-27.
22. Tryba M. Prophylaxis of stress ulcer bleeding. A meta-analysis. J Clin Gastroenterol. 1991; 13 Suppl 2:S44-55.
23. Cook DJ, Reeve BK, Guyatt GH, Heyland DK, Griffith LE, Buckingham L, et al. Stress ulcer prophylaxis in critically ill patients. Resolving discordant metaanalyses. JAMA 1996; 275 (4): 308-14.
24. Lin P, Chang Ch, Hsu P, Tseng P, Huang Y. The efficacy and safety of protom pump inhibitors vs histamine-2 receptor antagonist for stress ulcer bleeding prophylaxis among critical care patients: A metanalysis. Crit Care Med. 2010: 38(4): 1197-1205.
25. Pham CQ, Regal RE, Bostwick TR, Knauf KS. Acid suppressive therapy use on an inpatient internal medicine service. Ann Pharmacother. 2006 Jul-Aug; 40(7-8):1261-6.
26. Nardino RJ, Vender RJ, Herbert PN. Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol. 2000 Nov; 95(11):3118-22.
27. Noguerado Asensio A, Rodriguez Barrientos R, Zelaya Castro P, Sanchez Sempere A, Antuna Blanco F, Lutz Garcia E, et al. [Use of acid-suppressive medications in hospitalized patients]. An Med Interna. 2002 Nov; 19(11):557-60.
28. Zink DA, Pohlman M, Barnes M, Cannon ME. Long-term use of acid suppression started inappropriately during hospitalization. Aliment Pharmacol Ther. 2005 May 15; 21(10):1203-9.
29. Khudair IF, Sadik ND, Hanssens YI. Prescribing pattern of acid suppressive medications for medical inpatients in a teaching hospital in Qatar. Saudi Med J. 2009 Jan; 30(1):125-9.
30. Zeitoun A, Zeineddine M, Dimassi H. Stress ulcer prophylaxis guidelines: Are they being implemented in Lebanese health care centers? World J Gastrointest Pharmacol Ther. 2011; 2(4): 27-35
31. Bez C, Perrottet N, Zingg T, Leung Ki EL, Demartines N, Pannatier A. Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department. J Eval Clin Pract. 2013 Apr; 19(2):374-8.
32. Gupta R, Garg P, Kottoor R, Munoz JC, Jamal MM, Lambiase LR, et al. Overuse of Acid Suppression Therapy in Hospitalized Patients. South Med J. 2010; 103(3): 207-11.
33. Hussain S, Stefan M, Visintainer P, Rothberg M. Why Do Physicians Prescribe Stress Ulcer Prophylaxis to General Medicine Patients? Sout Med J. 2010; 103(11): 1103-10.
34. Issa I, Soubra O, Nakkash H, Soubra L. Variables Associated with Stress Ulcer Prophylaxis Misuse: A Retrospective Analysis. Dig Dis Sci. 2012 Oct; 57(10):2633-41.
35. Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA. 2005 Dec 21; 294(23):2989-95.
36. Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ. 2004 Jul 6; 171(1):33-8.
37. Lowe DO, Mamdani MM, Kopp A, Low DE, Juurlink DN. Proton pump inhibitors and hospitalization for Clostridium difficile-associated disease: a population-based study. Clin Infect Dis. 2006 Nov 15; 43(10):1272-6.
38. Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004 Oct 27; 292(16):1955-60.
39. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009 May 27; 301(20):2120-8.
40. Laine L. Protom pump inhibitors and bone fractrures?. 2009 Mar; 104 Suppl 2:S21-6.
41. Eom CS, Park SM, Myung SK, Yun JM, Ahn JS. Use of Acid- Suppressive Drugs and Risk of Fracture: A Meta-analysis of Observational Studies. Ann Fam Med. 2011; 11(9): 257-67.
42. Erstad BL, Camamo JM, Miller MJ, Webber AM, Fortune J. Impacting cost and appropriateness of stress ulcer prophylaxis at a university medical center. Crit Care Med. 1997 Oct; 25(10):1678-84.
43. Wadibia EC, Lucas BD, Hilleman DE, Mooss AN. Economic impact of inappropiate histamine 2-receptor antagonist use. Clin Ther. 1997 Sep-Oct; 19(5):1085-91.
44. Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006 Oct; 101(10):2200-5.
45. Saultz A, Judkins DZ, Saultz JW, Fashner J. What Gl stress ulcer prophylaxis should we provide hospitalized patients?. J Fam Prac. 2007; 56(1): 51-2.
46. Kleb FH, Scholmerich J. Future expectations in the prophylaxis of intestinal bleeding. Best Pract Res Clin Gastroenterol. 2008; 22(2):373-87.
47. Lanza F, Chan F, Quigley E. Guidelines for prevention of NSAID-Related ulcer complications. Am J Gastroenterol. 2009; 104(3): 728-38.
48. Guillamondegui OD, Gunter OL Jr, Bonadies JA, Coates JE, Kurek SJ, De Moya MA. Practice management guidelines for stress ulcer prophylaxis [monografía en Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2008 [citado 24 Jul 2013]. Disponible en: http://guidelines.gov/content.aspx?id=12635.
49. Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012 Jun 13; 344:e3412.
50. Yachimski PS, Farrell EA, Hunt DP, Reid AE. Proton pump inhibitors for prophylaxis of nosocomial upper gastrointestinal tract bleeding: effect of standardized guidelines on prescribing practice. Arch Intern Med. 2010 May 10; 170(9):779-83.
51. Khalili H, Dashti-Khavidaki S, Hossein Talasaz A, Tabeefar H, Hendoiee N. Descriptive Analysis of a Clinical Pharmacy Intervention to Improve the Appropriate Use of Stress Ulcer Prophylaxis in a Hospital Infectious Disease Ward. J Manag Care Pharm. 2010; 16(2):114-21.
52. Coursol C, Sanzari S. Impact of Stress Ulcer Prophylaxis Algorithm Study. Ann Pharmacother. 2005; 39:810-6.
2. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm. 2007 Jul 1; 64(13):1396-400.
3. Fennerty MB. Pathophysiology of the upper gastrointestinal tract in the critically ill patient: rationale for the therapeutic benefits of acid suppression. Crit Care Med. 2002 Jun; 30(6 Suppl):S351-5.
4. Mutlu GM, Mutlu EA, Factor P. GI complications in patients receiving mechanical ventilation. Chest. 2001;119(4):1222-41.
5. Metz DC. Preventing the gastrointestinal consequences of stress-related mucosal disease. Curr Med Res Opin. 2005 Jan; 21(1):11-8.
6. Quenot JP, Thiery N, Barbar S. When should stress ulcer prophylaxis be used in the ICU?. Curr Opin Crit Care. 2009; 15:139-43.
7. Amaral MC, Favas C, Alves JD, Riso N, Riscado MV. Stress-related mucosal disease: Incidence of bleeding and the role of omeprazole in its prophylaxis. Eur J Int Med. 2010; 21(5):386-88.
8. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006 Jan; 1(1):13-20.
9. Herzig SJ, Vaughn BP, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for nosocomial gastrointestinal tract bleeding. Arch Intern Med. 2011 Jun 13; 171(11):991-7.
10. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med. 1994 Feb 10; 330(6):377-81.
11. Cook D, Heyland D, Griffith L, Cook R, Marshall J, Pagliarello J. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. Crit Care Med. 1999 Dec; 27(12):2812-7.
12. Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002 Jun; 30 (6 Suppl):S362-4.
13. Stollman N, Metz DC. Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care. 2005 Mar; 20(1):35-45.
14. Martindale RG. Contemporary strategies for the prevention of stress-related mucosal bleeding. Am J Health Syst Pharm. 2005 May 15; 62(10 Suppl 2):S11-7.
15. Terdiman JP, Ostroff JW. Gastrointestinal bleeding in the hospitalized patient: a case-control study to assess risk factors, causes, and outcome. Am J Med. 1998 Apr; 104(4):349-54.
16. Estruch R, Pedrol E, Castells A, Masanes F, Marrades RM, Urbano-Marquez A. Prophylaxis of gastrointestinal tract bleeding with magaldrate in patients admitted to a general hospital ward. Scand J Gastroenterol. 1991 Aug; 26(8):819-26.
17. Grau JM, Casademont J, Fernandez-Sola J, Cardellach F, Urbano-Marquez A. Prophylaxis of gastrointestinal tract bleeding in patients admitted to a general hospital ward. Comparative study of sucralfate and cimetidine. Scand J Gastroenterol. 1993 Mar; 28(3):244-8.
18. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999 Feb 15; 56(4):347-79.
19. Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. N Engl J Med. 1998 Mar 19; 338(12):791-7.
20. Conrad SA, Gabrielli A, Margolis B, Quartin A, Hata JS, Frank WO, et al. Randomized, double blind comparison of immediate-release omeprazole-oral suspension versus intravenous cimetidina for prevention of upper gastrointestinal bleeding in critically ill patients. Crit Care Med. 2005; 33(4):760-65.
21. Cook DJ, Witt LG, Cook RJ, Guyatt GH. Stress ulcer prophylaxis in the critically ill. A meta-analysis. Am J Med. 1991 Nov; 91(5):519-27.
22. Tryba M. Prophylaxis of stress ulcer bleeding. A meta-analysis. J Clin Gastroenterol. 1991; 13 Suppl 2:S44-55.
23. Cook DJ, Reeve BK, Guyatt GH, Heyland DK, Griffith LE, Buckingham L, et al. Stress ulcer prophylaxis in critically ill patients. Resolving discordant metaanalyses. JAMA 1996; 275 (4): 308-14.
24. Lin P, Chang Ch, Hsu P, Tseng P, Huang Y. The efficacy and safety of protom pump inhibitors vs histamine-2 receptor antagonist for stress ulcer bleeding prophylaxis among critical care patients: A metanalysis. Crit Care Med. 2010: 38(4): 1197-1205.
25. Pham CQ, Regal RE, Bostwick TR, Knauf KS. Acid suppressive therapy use on an inpatient internal medicine service. Ann Pharmacother. 2006 Jul-Aug; 40(7-8):1261-6.
26. Nardino RJ, Vender RJ, Herbert PN. Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol. 2000 Nov; 95(11):3118-22.
27. Noguerado Asensio A, Rodriguez Barrientos R, Zelaya Castro P, Sanchez Sempere A, Antuna Blanco F, Lutz Garcia E, et al. [Use of acid-suppressive medications in hospitalized patients]. An Med Interna. 2002 Nov; 19(11):557-60.
28. Zink DA, Pohlman M, Barnes M, Cannon ME. Long-term use of acid suppression started inappropriately during hospitalization. Aliment Pharmacol Ther. 2005 May 15; 21(10):1203-9.
29. Khudair IF, Sadik ND, Hanssens YI. Prescribing pattern of acid suppressive medications for medical inpatients in a teaching hospital in Qatar. Saudi Med J. 2009 Jan; 30(1):125-9.
30. Zeitoun A, Zeineddine M, Dimassi H. Stress ulcer prophylaxis guidelines: Are they being implemented in Lebanese health care centers? World J Gastrointest Pharmacol Ther. 2011; 2(4): 27-35
31. Bez C, Perrottet N, Zingg T, Leung Ki EL, Demartines N, Pannatier A. Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department. J Eval Clin Pract. 2013 Apr; 19(2):374-8.
32. Gupta R, Garg P, Kottoor R, Munoz JC, Jamal MM, Lambiase LR, et al. Overuse of Acid Suppression Therapy in Hospitalized Patients. South Med J. 2010; 103(3): 207-11.
33. Hussain S, Stefan M, Visintainer P, Rothberg M. Why Do Physicians Prescribe Stress Ulcer Prophylaxis to General Medicine Patients? Sout Med J. 2010; 103(11): 1103-10.
34. Issa I, Soubra O, Nakkash H, Soubra L. Variables Associated with Stress Ulcer Prophylaxis Misuse: A Retrospective Analysis. Dig Dis Sci. 2012 Oct; 57(10):2633-41.
35. Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA. 2005 Dec 21; 294(23):2989-95.
36. Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ. 2004 Jul 6; 171(1):33-8.
37. Lowe DO, Mamdani MM, Kopp A, Low DE, Juurlink DN. Proton pump inhibitors and hospitalization for Clostridium difficile-associated disease: a population-based study. Clin Infect Dis. 2006 Nov 15; 43(10):1272-6.
38. Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004 Oct 27; 292(16):1955-60.
39. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009 May 27; 301(20):2120-8.
40. Laine L. Protom pump inhibitors and bone fractrures?. 2009 Mar; 104 Suppl 2:S21-6.
41. Eom CS, Park SM, Myung SK, Yun JM, Ahn JS. Use of Acid- Suppressive Drugs and Risk of Fracture: A Meta-analysis of Observational Studies. Ann Fam Med. 2011; 11(9): 257-67.
42. Erstad BL, Camamo JM, Miller MJ, Webber AM, Fortune J. Impacting cost and appropriateness of stress ulcer prophylaxis at a university medical center. Crit Care Med. 1997 Oct; 25(10):1678-84.
43. Wadibia EC, Lucas BD, Hilleman DE, Mooss AN. Economic impact of inappropiate histamine 2-receptor antagonist use. Clin Ther. 1997 Sep-Oct; 19(5):1085-91.
44. Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006 Oct; 101(10):2200-5.
45. Saultz A, Judkins DZ, Saultz JW, Fashner J. What Gl stress ulcer prophylaxis should we provide hospitalized patients?. J Fam Prac. 2007; 56(1): 51-2.
46. Kleb FH, Scholmerich J. Future expectations in the prophylaxis of intestinal bleeding. Best Pract Res Clin Gastroenterol. 2008; 22(2):373-87.
47. Lanza F, Chan F, Quigley E. Guidelines for prevention of NSAID-Related ulcer complications. Am J Gastroenterol. 2009; 104(3): 728-38.
48. Guillamondegui OD, Gunter OL Jr, Bonadies JA, Coates JE, Kurek SJ, De Moya MA. Practice management guidelines for stress ulcer prophylaxis [monografía en Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2008 [citado 24 Jul 2013]. Disponible en: http://guidelines.gov/content.aspx?id=12635.
49. Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012 Jun 13; 344:e3412.
50. Yachimski PS, Farrell EA, Hunt DP, Reid AE. Proton pump inhibitors for prophylaxis of nosocomial upper gastrointestinal tract bleeding: effect of standardized guidelines on prescribing practice. Arch Intern Med. 2010 May 10; 170(9):779-83.
51. Khalili H, Dashti-Khavidaki S, Hossein Talasaz A, Tabeefar H, Hendoiee N. Descriptive Analysis of a Clinical Pharmacy Intervention to Improve the Appropriate Use of Stress Ulcer Prophylaxis in a Hospital Infectious Disease Ward. J Manag Care Pharm. 2010; 16(2):114-21.
52. Coursol C, Sanzari S. Impact of Stress Ulcer Prophylaxis Algorithm Study. Ann Pharmacother. 2005; 39:810-6.
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