PPI Drip Regimen
For bleeding peptic ulcers after endoscopic hemostasis, administer an 80 mg intravenous bolus of a PPI followed by continuous infusion at 8 mg/hour for 72 hours. 1
Standard High-Dose Regimen
The evidence-based protocol for PPI drip therapy consists of:
- Initial bolus: 80 mg IV push 1
- Continuous infusion: 8 mg/hour for 72 hours 1
- Total dose: 656 mg over 3 days 1
This regimen applies to esomeprazole, pantoprazole, or omeprazole, as this is considered a class effect. 1
Clinical Context and Timing
Start PPI therapy as soon as possible, ideally before endoscopy. 1 While pre-endoscopy administration may reduce stigmata of bleeding and decrease the need for endoscopic therapy, the high-dose infusion protocol is specifically indicated after successful endoscopic hemostasis for high-risk lesions (Forrest 1a, 1b, 2a, or 2b). 1
Evidence Supporting This Regimen
The 2020 World Society of Emergency Surgery guidelines recommend this protocol based on a landmark RCT of 767 patients showing that 80 mg bolus plus 8 mg/hour infusion significantly reduced rebleeding (5.9% vs 10.3%, p=0.03) and need for repeat endoscopy compared to placebo. 1 Meta-analyses confirm this regimen reduces rebleeding, need for surgery, and mortality. 1
Administration Details
Administer as intravenous infusion over 2-15 minutes for the bolus, followed by continuous infusion. 2 The FDA-approved pantoprazole formulation can be given as either a 2-minute or 15-minute infusion. 2
- Reconstitute the 40 mg vial according to package instructions 2
- For the bolus: give 80 mg (two vials) 2
- For continuous infusion: prepare appropriate concentration to deliver 8 mg/hour 1
After the 72-Hour Infusion
Transition to oral PPI therapy after 72 hours. 1 The International Consensus Group (2019) recommends:
- Days 4-14: Oral PPI twice daily for patients at high risk for rebleeding 1
- After day 14: Once-daily oral PPI 1
- Duration: Continue for 6-8 weeks total following endoscopic treatment 1
Important Caveats
Do not use PPI infusion as a replacement for urgent endoscopy. 1 The primary treatment for active bleeding is endoscopic hemostasis; PPI therapy is adjunctive. 1
Be aware of conflicting evidence on dose. While the high-dose regimen is widely recommended, a Cochrane review found insufficient evidence to prove superiority over lower doses. 1 However, a 2014 RCT comparing high-dose (80 mg bolus + 8 mg/hour) versus low-dose (40 mg bolus + 4 mg/hour) pantoprazole found no significant difference in rebleeding, surgery, or mortality. 3 Despite this equipoise, the consensus guidelines favor the high-dose regimen based on the totality of evidence and biological plausibility. 1
Special Populations
For Zollinger-Ellison syndrome or pathological hypersecretion, the regimen differs significantly:
- Initial dose: 80 mg IV every 12 hours 2, 4, 5
- Maximum dose: Up to 240 mg/24 hours if needed 4, 5
- Titration: Adjust based on gastric acid output measurements 4, 5
This population requires 80 mg every 12 hours (not continuous infusion) with upward titration as needed, as 93% of ZES patients achieve control at this dose. 4