Keywords: PPI, Gi bleed (PubMed Search)
Continuous vs intermittent dosing of PPIs in bleeding peptic ulcer disease
There continues to be debate as to the optimal dose, frequency, and route of proton pump inhibitors (PPIs) in bleeding ulcers, especially prior to endoscopy. Multiple guidelines including from the American Journal of Gastroenterology continue to recommend continuous dosing of PPIs.1,2,3 However, multiple studies appear to show at least non-inferiority when compared with intermittent dosing of PPIs.
The most frequently cited study for non-inferiority is a meta-analysis of 13 randomized control trials by Sachar et al. which evaluated PPI use in patients presenting with upper GI bleeds who were endoscopically found to have a bleeding gastric or duodenal ulcer with high risk features (active bleeding, non-bleeding visible vessel, or adherent clot)4. There was non-inferiority of intermittent dosing in rebleeding, need for repeat endoscopy/surgery, RBC transfusions, and mortality with a non-statistically significant trend towards superiority of intermittent dosing.
However, the patients were only randomized to continuous vs intermittent dosing AFTER endoscopic treatment. In addition, the dosing regimen of intermittent dosing was quite variable.