What is the best way to administer Proton Pump Inhibitors (PPIs) to ulcer patients in emergency situations?

How to Give PPI in Ulcer Patients in Emergency

For bleeding peptic ulcers in the emergency setting, administer pantoprazole 80 mg IV bolus immediately, followed by continuous infusion of 8 mg/hour for 72 hours after successful endoscopic hemostasis. 1, 2

Immediate Pre-Endoscopy Management

Start PPI therapy as soon as possible, even before endoscopy is performed. 3, 1 This approach reduces stigmata of recent bleeding at index endoscopy and may decrease the need for endoscopic therapy. 3

Pre-Endoscopy Adjuncts

• Administer erythromycin 250 mg IV 30-60 minutes before endoscopy to improve gastric visualization and reduce need for repeat endoscopy. 3, 1
• Do not delay urgent endoscopy while waiting for PPI to take effect—endoscopic intervention remains first-line treatment. 1, 2

Specific Dosing Protocol

Initial Bolus

• Pantoprazole 80 mg IV bolus (or omeprazole 80 mg IV) administered over 2-5 minutes. 1, 2

Continuous Infusion

• 8 mg/hour continuous IV infusion for 72 hours after successful endoscopic hemostasis. 3, 1, 2
• This high-dose regimen maintains gastric pH >6, which is necessary for platelet aggregation and clot stability. 1

Reconstitution and Administration (Pantoprazole)

• Reconstitute 40 mg vial with 10 mL of 0.9% Sodium Chloride, 5% Dextrose, or Lactated Ringer's solution. 4
• For continuous infusion: add two reconstituted vials (80 mg total) to 100 mL of compatible solution. 4
• Incompatible with midazolam and products containing zinc—discontinue if precipitation occurs. 4

Post-Endoscopy Transition

Days 4-14

• Switch to oral PPI: omeprazole 40 mg twice daily or pantoprazole 40 mg twice daily. 2

Weeks 2-8

• Continue oral PPI 40 mg once daily for total duration of 6-8 weeks to allow complete mucosal healing. 3, 1, 2
• Long-term PPI beyond 8 weeks is not recommended unless patient has ongoing NSAID use. 3, 1

Evidence Supporting High-Dose Regimen

High-dose IV PPI significantly reduces:

• Rebleeding: 5.9% vs 10.3% with placebo (p=0.03). 3, 2
• Need for surgery: 8.4% vs 13.0% with control (OR 0.59). 2
• Need for repeat endoscopy: significant reduction after endoscopic therapy. 3, 2

Mortality benefit is modest (OR 0.56,95% CI 0.34-0.94) because most deaths result from comorbidities rather than rebleeding itself. 2

Essential Concurrent Management

H. pylori Testing

• Test all patients with bleeding peptic ulcers for H. pylori infection. 1, 2
• Provide eradication therapy if positive—failure to treat leads to 40-50% recurrence over 10 years. 1, 2

NSAID Management

• Discontinue NSAIDs when possible. 1
• If NSAIDs must continue, maintain long-term PPI therapy. 3, 1

Alternative Consideration: Oral PCAB

Emerging evidence suggests oral potassium competitive acid blockers (PCABs) like tegoprazan 50 mg may be superior to IV PPI bolus alone when given pre-endoscopy, with lower rates of high-risk lesions (Forrest IIa or higher) and reduced rebleeding. 5 However, this represents a single 2025 study and is not yet incorporated into guidelines—stick with the established high-dose IV PPI protocol until more evidence emerges. 5

Common Pitfalls to Avoid

• Never stop PPI before 6-8 weeks—inadequate duration prevents complete mucosal healing. 1, 2
• Never use low-dose or intermittent bolus dosing in high-risk patients (Forrest Ia, Ib, IIa, IIb)—continuous infusion is required for efficacy. 2
• Never rely solely on PPI without endoscopic intervention in active bleeding—this is ineffective. 1, 2
• Never forget H. pylori testing—this is the most common cause of treatment failure and recurrence. 1, 2
• Watch for thrombophlebitis at IV site—consider changing access if inflammation develops. 4

Special Populations

Severe Hepatic Impairment (Child-Pugh C)

• Reduce dose to 15 mg daily when transitioning to oral therapy. 6

Patients with Comorbidities

• Consider extending IV PPI infusion up to 7 days in patients with significant comorbidities, as rebleeding risk remains elevated. 7