UMEM Educational Pearls

Title: PPI Bolus + Infusion vs. Intermittent Bolus for Upper GI Hemorrhage

Keywords: PPI, GI bleed, UGIB, GI hemorrhage (PubMed Search)

Posted: 6/7/2016 by Daniel Haase, MD
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Current guidelines recommend IV proton pump inhibitors in setting of acute upper GI hemorrhage as a bolus + infusion (e.g. 80 mg bolus + 8mg/hr infusion).
Recent meta-analysis comparing bolus + infusion versus intermittent bolus (most commonly 40 mg BID) demonstrated non-inferiority of intermittent bolus dosing.
In fact, there was a trend (though not significant) to superiority of intermittent bolus dosing, with decreases in rebleeding, mortality, repeat intervention.
From a practical standpoint, pantoprazole requires a dedicated IV line, and is not compatible with other common ICU infusions (fentanyl, propofol, norepinephrine, octreotide).

References

1. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60; quiz 361. doi: 10.1038/ajg.2011.480. Epub 2012 Feb 7. Review. PubMed PMID: 22310222.

2. Barkun AN, et al; International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19;152(2):101-13. doi: 10.7326/0003-4819-152-2-201001190-00009. PubMed PMID: 20083829.

3. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014 Nov;174(11):1755-62. doi: 10.1001/jamainternmed.2014.4056. Review. PubMed PMID: 25201154; PubMed Central PMCID: PMC4415726.

4. Neumann I, et aI. Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2013 Jun 12;(6):CD007999. doi: 10.1002/14651858.CD007999.pub2. Review. PubMed PMID: 23760821.

5. Pantoprazole. Micromedex 2.0. Truven Health Analytics, Inc. Available at http://micromedexsoultsions. Accessed June 7, 2016.