A recent systemic review and meta-analysis (JAMA Intern Med. doi10.10001/jamainternmed.2014.4056) calls into question the practive of using continous intravenous proton pump inhibitor (PPI) for high-risk bleeding ulcers.

“Current guidelines recommend an intravenous bolus dose of a proton pump inhibitor (PPI) followed by continuous PPI infusion after endoscopic therapy in patients wtih high-risk bleeding ulcers.  Substitution of intermittent PPI therapy, if similarly effective as bolus plus continous-infusion PPI therapy, would decrease the PPI dose, costs, and resource use.”

Ultimately, only randomized 13 studies (Table 1) were identified that examined only high-risk ulcers, and used appropriate treatment protocols.  Table 2 lists the results with regard to recurrent bleeding, mortality, surgery, blood transfusions, and length of hospital stay as well as the number of patients; 1691 patients had data for rebleeding within 30 days.  Typically, intermittent PPI dosage was 40-80 mg BID.

Key findings:

• There was not an increased risk of rebleeding with intermittent vs bolus-continuous; at 7 days, the risk ratio was 0.72 favoring intermittent treatment and the absolute difference was -2.64% (predefined noninferiority was a margin of 3%)
• The absolute risk difference for all outcomes was less than 1.5% for all rebleeding outcomes.  Using the 95% confidence interval for absolute risk difference, the values were -0.28, 0.17, and 1.49for rebleeding within 7 days, 3 days, and 30 days.

Bottomline: this systemic review indicates that intermittent PPI therapy may be similarly effective as continuous drip PPI for meaningful outcomes in high-risk bleeding ulcers.

Related blog post:

All bleeding stops | gutsandgrowth