What is the recommended use of Proton Pump Inhibitors (PPIs) in post-surgical or admitted patients at risk of gastrointestinal bleeding?

From the Guidelines

Proton Pump Inhibitors (PPIs) are recommended for stress ulcer prophylaxis in high-risk hospitalized or post-surgical patients, particularly those with specific risk factors such as mechanical ventilation, coagulopathy, or history of GI bleeding, as supported by the most recent and highest quality study 1.

Key Points

• PPI prophylaxis should be initiated with intravenous PPIs such as pantoprazole 40mg or esomeprazole 40mg once daily for critically ill patients, transitioning to oral formulations when patients can tolerate oral intake, as suggested by 1.
• Common oral options include omeprazole 20-40mg, pantoprazole 40mg, or esomeprazole 20-40mg daily.
• Therapy should be discontinued upon resolution of risk factors or at hospital discharge unless there are other indications for continued use.
• PPIs work by irreversibly inhibiting the hydrogen-potassium ATPase enzyme in gastric parietal cells, reducing acid production and raising gastric pH above 4, which helps prevent stress-related mucosal damage.

Rationale

The use of PPIs in high-risk hospitalized or post-surgical patients is supported by the most recent and highest quality study 1, which suggests that high-dose PPIs after endoscopic therapy significantly reduce rebleeding, need for surgery, and mortality compared with placebo/no therapy.

Important Considerations

• The quality of evidence for concomitant PPI prophylaxis is deemed moderate due to a lack of comparative outcome data being available in the studies, as noted in 1.
• Future studies that include a comparator group and assess the optimal dosing, frequency, and duration of PPI administration in patients with obesity receiving IGB therapy are warranted, as suggested by 1.
• The role of acid suppression in the treatment of peptic ulcer and its complications is well known, but the dosage and the duration of PPI administration for the treatment of bleeding peptic ulcer are still a matter of debate, as discussed in 1 and 1.

From the Research

Recommended Use of Proton Pump Inhibitors (PPIs) in Post-Surgical or Admitted Patients

The use of Proton Pump Inhibitors (PPIs) in post-surgical or admitted patients at risk of gastrointestinal bleeding is a topic of ongoing debate. Key points to consider include:

• The efficacy of PPIs in reducing the risk of recurrent bleeding in patients with peptic ulcer disease, as demonstrated in a case report where an intravenous PPI (pantoprazole) was used to treat upper gastrointestinal bleeding in a patient with short bowel syndrome 2.
• The comparison of intermittent PPI therapy with continuous PPI infusion after endoscopic therapy in patients with high-risk bleeding ulcers, which found that intermittent PPI therapy is comparable to the current guideline-recommended regimen 3.
• The role of PPIs in the management of upper gastrointestinal bleeding, including their use in pre-endoscopic administration and endoscopically diagnosed peptic ulcer bleeding, with evidence supporting their efficacy in reducing rebleeding rates 4.

Considerations for Appropriate Use

When considering the use of PPIs in post-surgical or admitted patients, the following points should be taken into account:

• The potential benefits of PPIs in reducing the risk of upper gastrointestinal bleeding must be weighed against the potential risks, including an increased risk of hospital-acquired pneumonia and Clostridium difficile infection 5.
• The appropriate use of PPIs, including the treatment of gastro-esophageal reflux disease, eradication of Helicobacter pylori infection, and therapy of H. pylori-negative peptic ulcers, as well as the healing and prophylaxis of non-steroidal anti-inflammatory drug-associated gastric ulcers 6.
• The need for a reappraisal of the use of PPIs, given the potential for overuse and the associated costs and risks, and the importance of educational initiatives to guide primary care physicians and specialists in the correct use of PPIs 6.

Key Findings

Some key findings from the available evidence include:

• Intravenous PPIs can be effective in controlling gastric acid hypersecretion and reducing the risk of recurrent bleeding in patients with peptic ulcer disease 2.
• Intermittent PPI therapy is comparable to continuous PPI infusion in patients with high-risk bleeding ulcers 3.
• PPIs can reduce rebleeding rates in patients with endoscopically diagnosed peptic ulcer bleeding, but their use in pre-endoscopic administration is still a topic of debate 4.
• The use of PPIs in hospitalized patients may lead to a net increase in hospital mortality, except in patients at high risk of upper gastrointestinal bleeding and low risk of hospital-acquired pneumonia and Clostridium difficile infection 5.