Initial IV PPI Dose for Upper GI Bleeding
The recommended initial dose is an 80 mg IV bolus of a proton pump inhibitor (omeprazole or pantoprazole), followed immediately by continuous infusion at 8 mg/hour for 72 hours. 1, 2, 3
Dosing Protocol
Initial Bolus and Infusion
- Administer 80 mg IV bolus immediately, even before endoscopy is performed 1, 2, 4
- Follow with continuous infusion at 8 mg/hour for 72 hours after endoscopic therapy 1, 2, 3
- This high-dose regimen represents a Grade A recommendation with Level I evidence from consensus guidelines 1, 2
Rationale for Continuous Infusion
- Continuous infusion maintains gastric pH above 6, which is critical for platelet aggregation and clot stability 3
- This regimen has demonstrated significant reductions in:
Pre-Endoscopy Considerations
- Start the 80 mg bolus and continuous infusion immediately upon presentation, even before endoscopy 1, 2, 4
- This pre-endoscopy use carries a Grade C recommendation (weaker evidence) but has an excellent safety profile 1
- PPI therapy must never replace or delay urgent endoscopy—it is adjunctive therapy only 1, 4, 3
Post-Infusion Transition
After completing the 72-hour IV infusion:
- Days 4-14: Transition to oral PPI 40 mg twice daily 2, 4, 3
- Day 15 onward: Continue oral PPI 40 mg once daily for 6-8 weeks total to allow complete mucosal healing 2, 4, 3
Class Effect and Agent Selection
- The benefits are considered a class effect—either omeprazole or pantoprazole can be used with equivalent efficacy 1
- The specific regimen of 80 mg bolus followed by 8 mg/hour infusion applies to both agents 1
Common Pitfalls to Avoid
Inadequate Dosing
- Do not use lower doses such as 40 mg bolus with 4 mg/hour infusion—one study showed no difference between high and low doses 5, but guideline consensus strongly supports the 80 mg/8 mg per hour regimen based on multiple trials and meta-analyses 1
- Do not use intermittent IV push dosing alone (e.g., 40 mg every 12 hours) as the initial regimen, as this does not maintain adequate gastric pH 1
Timing Errors
- Do not delay PPI initiation waiting for endoscopy—start immediately 1, 2, 4
- Do not stop the continuous infusion prematurely before 72 hours in high-risk patients 1, 2
Misapplication
- Benefits are most pronounced in patients with high-risk endoscopic stigmata (active bleeding, visible vessel, or adherent clot) 1, 2, 3
- For low-risk lesions (clean-based ulcers), the aggressive regimen may not be necessary, though many clinicians continue it based on pre-endoscopy uncertainty 1
Additional Management Points
- Test all patients for H. pylori and provide eradication therapy if positive, as this reduces recurrent bleeding risk 1, 2, 4, 3
- Consider pre-endoscopy erythromycin to enhance gastric visualization during endoscopy 4, 3
- Early endoscopy (within 24 hours) should be performed, but not necessarily urgent (<12 hours) unless hemodynamically unstable 6