Pre and post endoscopic use of IV proton pump inhibtors in acute non-variceal upper gastrointestinal bleeds, bolus vs infusion
Date First Published:
October 22, 2002
Last Updated:
March 10, 2010
Report by:
Dr Paul Yap, Senior Clinical Fellow Gastroenterology ( Stepping Hill Hospital NHS Foundation Trust )
Search checked by:
Paul Yap, Stepping Hill Hospital NHS Foundation Trust
Three-Part Question:
In [acute non variceal upper GI bleed] is [ continuous infusion or bolus infusions of iv proton pump inhibitor better] at [reducing mortality] pre-endoscopy
Clinical Scenario:
A 45 years old man with known history of peptic ulcer disease is admitted with haematemesis and malaena. The is no history or stigmata of chronic liver disease to suspect varices. You want to know whether giving proton pump inhibitors (PPI) as intermittent intravenous (IV) bolus dose is as effective as as a continuous IV infusion pre endoscopy.
Search Strategy:
Pubmed search
Date: all to present
Date: all to present
Search Details:
((((((("proton pump inhibitors"[MeSH Terms] OR ("proton"[All Fields] AND "pump"[All Fields] AND "inhibitors"[All Fields]) OR "proton pump inhibitors"[All Fields]) OR ("lansoprazole"[Substance Name] OR "lansoprazole"[All Fields])) OR ("pantoprazole"[Substance Name] OR "pantoprazole"[All Fields])) OR ("omeprazole"[MeSH Terms] OR "omeprazole"[All Fields] OR "esomeprazole"[All Fields])) OR ("omeprazole"[MeSH Terms] OR "omeprazole"[All Fields])) AND ("ulcer"[MeSH Terms] OR "ulcer"[All Fields])) AND infusion[All Fields]) AND bolus[All Fields] AND ("humans"[MeSH Terms] AND English[lang] AND "adult"[MeSH Terms])
Outcome:
34 papers found. 5 papers were relevant although there were no papers directly comparing PPI continuous infusion agasint PPI intermittent bolus doses pre endoscopy.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intermittent versus continuous pantoprazole infusion in peptic ulcer bleeding: a prospective randomized study Yüksel I, Ataseven H, Köklü S, Ertuğrul I, Başar O, Odemiş B, Ibiş M, Saşmaz N, Sahin B 2008 Ankara, Turkey | 97 patients admitted with non-variceal upper GI bleed over 3 years. All had some form of endoscopic intervention and were subsequently randomised to recieve either a bolus of 80mg Pantoprazole followed by a continuous infusion of 8mg/day for 72 hours or IV bolus infusion of 40mg 12 hourly for 72 hours | Prospective randomized study | Rebleeding rate | No significant difference between the 2 groups | Did not distinguish between H.pylori status. Although there was no significance between the 2 groups. Relatively short follow up time of 3 days. |
| Duration of stay in hospital | No significant difference between the 2 groups | ||||
| Need for total blood transfusion | No significant difference between the 2 groups | ||||
| Need for surgery | No significant difference between the 2 groups | ||||
| Intravenous proton-pump inhibitor for acute peptic ulcer bleeding--is profound acid suppression beneficial to reduce the risk of rebleeding? Garrido A, Giráldez A, Trigo C, Leo E, Guil A, Márquez JL. 2008 Spain | 41 patients randomized into 2 groups. Group 1 recieved pantoprazole 80mg bolus followed by 8mg/hr continuous infusion for 72 hours and group 2 recieved daily bolus of pantoprazole 40mg for 72 hours. | Prospective randomised study | Recurrance of bleeding | no significant difference between the 2 groups | Relatively small numbers. Not much detail on endoscopic therapies performed. Some may argue that it was not originally in English. |
| Blood transfusion requirements | no significant difference between the 2 groups | ||||
| Need for surgery | no significant difference between the 2 groups | ||||
| Mortality | no significant difference between the 2 groups | ||||
| Randomized trial comparing pantoprazole infusion, bolus and no treatment on gastric pH and recurrent bleeding in peptic ulcers Hung WK, Li VK, Chung CK, Ying MW, Loo CK, Liu CK, Lam BY, Chan MC. 2007 Hong Kong | 153 patients post successful endoscopic therapy for bleeding peptic ulcers were randomised to receive either pantoprazole 80mg IV bolus followed by 8mg/hr infusion, pantoprazole 80mg IV bolus followed by 40mg IV bolus every 12 hours or no treatment. Treatments were conducted for 72 hours. | Prospective randomised trial. | Rebleeding within 30 days, | Fewer in bolus group but no difference between infusion or intermittent bolus | No placebo. Not blinded. Sub groups small numbers. |
| Transfusion requirements | Fewer in bolus group but no difference between infusion or intermittent bolus | ||||
| Mortality | No difference between groups | ||||
| Duration of Hospital Stay | No difference between groups | ||||
| Need for operation intervention | No difference between groups | ||||
| Gastric pH | pH was higher in infusion compared to intermittent bolus but no statistical significance | ||||
| Optimal dose of intravenous pantoprazole in patients with peptic ulcer bleeding requiring endoscopic hemostasis in Korea. Choi KD, Kim N, Jang IJ, Park YS, Cho JY, Kim JR, Shin JM, Jung HC, Song IS. Aug-09 South Korea | 61 patients with bleeding ulcers were randomized into one of three groups after endoscopic hemostasis: pantoprazole 80 mg bolus followed by 8mg/h; 40mg, 4mg/h infusion; and bolus injection of 40mg every 24h | Prospective, randomised study. No mention of blinding. Over period of 4 years. | Rebleeding rates within 30 days | No significant difference between groups | Solely Asian population. Unblinded. |
| Mean percentage time of patients with intragastric pH >6 | A continuous infusion, regardless of high or low dose, was more effective for acid suppression than a 40 mg bolus PPI injection in Korea. H. pylori infection was an important factor for the maintenance of an intragastric pH > 6. | ||||
| High- Versus Low-Dose Proton Pump Inhibitors After Endoscopic Hemostasis in Patients With Peptic Ulcer Bleeding: A Multicentre, Randomized Study Angelo Andriulli, M.D.; Silvano Loperfido, M.D.; Rosaria Focareta, M.D.; Pietro Leo, M.D.; Fabio Fornari, M.D.; Antonietta Garripoli, M.D.; Paolo Tonti, M.D.; Sergio Peyre, M.D.; Antonio Spadaccini, M Jan-09 Italian | A total of 482 patients with bleeding ulcers which received endoscopic haemostasis were randomised into 2 grouos. Group 1 received a intensive PPI regime; 80mg IV Bolus followed by 8mg/hr for 72 hours. Groupd 2 received a standard regime; 40mg bolus daily followed by saline infusion for 72hrs. Both pantoprazole and omeprazole were used in both groups. | Prospective, randomized, double-blind study. | Rebleeding rates | No significant differences between the groups | No significant weakness. |
| Mean units of blood transfused | No significant differences between the groups | ||||
| Duration of hospital stay | No significant differences between the groups | ||||
| Need for surgical intervention | No significant differences between the groups |
Author Commentary:
PPI treatment initiated for non-variceal gastrointestinal bleed is shown to reduce proportion of patients with stigmata of recent haemmorhage at endscopy and reduces the requirement for endoscopy therapy. However, there is no evidence that PPI treatment affects mortality, need for blood transfusion, rebleeding rates or need for surgery. These results were also mirrored in studies whereby PPI was started post endoscopic haemostasis. IV PPI provides more rapid increase in pH, reaching mean pH of 6 approximately 1 hour sooner than oral PPI.
Bottom Line:
There were no papers directly comparing benefits of continuous infusion PPI against intermittent IV bolus PPI pre-endoscopy. In the papers that compared IV PPI regimes post-endoscopic haemostasis, there was no significant difference in outcomes between the continuous IV infusion and intermittent IV bolus group.
References:
- Yüksel I, Ataseven H, Köklü S, Ertuğrul I, Başar O, Odemiş B, Ibiş M, Saşmaz N, Sahin B. Intermittent versus continuous pantoprazole infusion in peptic ulcer bleeding: a prospective randomized study
- Garrido A, Giráldez A, Trigo C, Leo E, Guil A, Márquez JL.. Intravenous proton-pump inhibitor for acute peptic ulcer bleeding--is profound acid suppression beneficial to reduce the risk of rebleeding?
- Hung WK, Li VK, Chung CK, Ying MW, Loo CK, Liu CK, Lam BY, Chan MC.. Randomized trial comparing pantoprazole infusion, bolus and no treatment on gastric pH and recurrent bleeding in peptic ulcers
- Choi KD, Kim N, Jang IJ, Park YS, Cho JY, Kim JR, Shin JM, Jung HC, Song IS.. Optimal dose of intravenous pantoprazole in patients with peptic ulcer bleeding requiring endoscopic hemostasis in Korea.
- Angelo Andriulli, M.D.; Silvano Loperfido, M.D.; Rosaria Focareta, M.D.; Pietro Leo, M.D.; Fabio Fornari, M.D.; Antonietta Garripoli, M.D.; Paolo Tonti, M.D.; Sergio Peyre, M.D.; Antonio Spadaccini, M. High- Versus Low-Dose Proton Pump Inhibitors After Endoscopic Hemostasis in Patients With Peptic Ulcer Bleeding: A Multicentre, Randomized Study