What is the recommended dose and frequency of Proton Pump Inhibitors (PPIs) for managing upper Gastrointestinal (GI) bleed?

Recommended PPI Dosing for Upper GI Bleeding

For patients with upper GI bleeding, high-dose PPI therapy with an 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic therapy is the recommended regimen to reduce rebleeding and mortality. 1

Initial Management of Upper GI Bleeding

• High-dose PPI therapy is strongly recommended for patients with bleeding ulcers with high-risk stigmata (active bleeding or visible vessel) who have undergone successful endoscopic therapy 1
• The standard high-dose regimen consists of an 80 mg IV bolus followed by continuous infusion at 8 mg/hour for 72 hours 1
• This regimen has been shown to significantly reduce rebleeding rates compared to H2-receptor antagonists or placebo 1
• Both intravenous omeprazole and pantoprazole can be used effectively with this dosing regimen 1

Pre-Endoscopy PPI Therapy

• In patients awaiting endoscopy, empirical therapy with a high-dose PPI should be considered 1
• This recommendation is based on biological plausibility and consensus, though with lower evidence quality (Grade C recommendation) 1
• Pre-endoscopy PPI administration may be cost-effective in certain situations 1

Post-Endoscopy PPI Therapy

• After the initial 72 hours of high-dose IV therapy, for patients at high risk of rebleeding, twice-daily oral PPIs are suggested through day 14 1
• After day 14, once-daily PPI therapy is appropriate 1
• For patients with adherent clots, either endoscopic therapy or PPI therapy alone may be considered 1

Evidence for High-Dose vs. Low-Dose PPI Therapy

• Multiple randomized trials have demonstrated that high-dose bolus and continuous-infusion PPIs reduce rebleeding and need for surgery compared with H2-receptor antagonists or placebo 1
• Meta-analyses confirm that high-dose PPI therapy after successful endoscopic therapy leads to statistically significant reduction in rebleeding rates 1
• While some recent studies suggest comparable outcomes between high-dose continuous infusion and intermittent bolus dosing 2, 3, the international consensus guidelines still strongly recommend high-dose continuous infusion based on more robust evidence 1

Common Pitfalls and Caveats

• PPI therapy is not a replacement for urgent endoscopy and hemostasis when appropriate 1
• The benefits of PPI therapy are most pronounced in patients with high-risk endoscopic stigmata 1
• PPIs are specifically indicated for upper GI bleeding but not lower GI bleeding such as diverticular bleeding 4, 5
• Inappropriate use of IV PPIs is common, with many patients receiving them before endoscopy and continuing after endoscopy despite low-risk findings 6
• Cost considerations may influence the choice between continuous infusion and intermittent dosing, but efficacy should be prioritized 1, 3

Additional Considerations

• Testing for Helicobacter pylori should be performed in patients with upper GI bleeding, and eradication therapy provided if infection is present 1
• Patients at low risk for rebleeding after endoscopy can be fed within 24 hours 1
• For patients on cardiovascular prophylaxis with antiplatelet therapy who have had previous ulcer bleeding, PPI therapy is suggested to reduce recurrent bleeding risk 1