Clinical Conundrum: Is there a difference in efficacy between PO and IV Proton Pump Inhibitors (PPIs) in the management of GI bleeds?
Background:
Upper gastrointestinal bleeds (UGIB) are caused by damage along the mucosal lining and the presence of gastric acid and pepsin.
Proton pump inhibitors (PPI) irreversibly inhibit proton pumps to decrease gastric acid secretion and increase intestinal pH.
Increasing intestinal pH > 6 inactivates pepsin and promotes mucosal protection.
Answer:
The current standard of care for UGIB treatment is IV PPI either as a continuous infusion or intermittent bolus dosing; however, ORAL PPI use has also been shown to be effective.
IV PPI regimens have shown faster onset of action in increasing the pH of the stomach with IV doses achieving a pH > 6 in 2 to 3 hours versus 3 to 4 hours with oral dosing.
Nevertheless, studies have shown no difference between IV versus oral PPI regimens in UGIB with regards to mortality, rebleeding rates, need for surgical intervention, blood transfusions, and duration of hospital stay.
Therefore, you can consider ORAL PPI use unless the following limitations exist for ORAL PPI's: restrictions on oral intake, critically ill patients where altered GI absorption is a concern, hemodynamically unstable, massive active GIB.
Reference:
Laine L, Jensen DM. ACG Practice Guidelines: Management of Patients with Ulcer Bleeding. Am J Gastroenterol. 2012; 107: 345 – 360.
Worden JC, Hanna KS. Optimizing proton pump inhibitor therapy for treatment of nonvariceal upper gastrointestinal bleeding. Am J Health-Syst Pharm. 2017; 74: 109 – 116.
Tringali A, Manta R, Sica M, et al. Comparing intravenous and oral proton pump inhibitor therapy for bleeding peptic ulcers following endoscopic management: a systematic review and meta-analysis. Br J Clin Pharmacol. 2017; 83(8): 1619 – 1635.
Written by:
Paula Krzos, Doctor of Pharmacy Candidate, Class of 2021
Reviewed by:
Joanne C. Routsolias, PharmD, RN, BCPS
Clinical PharmD Specialist - Emergency Medicine/Toxicology
Cook County Health