What is the appropriate dosing, preparation, and administration of intravenous esomeprazole for an adult patient who cannot take oral medication (e.g., NPO, active upper gastrointestinal bleeding, or intensive‑care unit stress‑ulcer prophylaxis), including infusion rate, repeat dosing, contraindications, and monitoring?

Esomeprazole Intravenous Drip for Upper Gastrointestinal Bleeding

Administer esomeprazole 80 mg IV bolus over 15–30 minutes, followed immediately by a continuous infusion of 8 mg/hour for exactly 72 hours after successful endoscopic hemostasis in patients with high-risk nonvariceal upper GI bleeding. 1, 2, 3

Patient Selection and Indications

• High-dose esomeprazole is indicated for patients with high-risk endoscopic stigmata: active arterial bleeding (Forrest Ia), oozing (Forrest Ib), visible vessel (Forrest IIa), or adherent clot (Forrest IIb). 1, 3
• This regimen reduces mortality (odds ratio 0.56,95% CI 0.34–0.94) and rebleeding rates (5.9% vs 10.3%, p = 0.03) compared with placebo or lower-dose regimens. 1, 2
• Patients with low-risk stigmata (clean-based ulcers, flat pigmented spots) do not require high-dose IV infusion and can be managed with standard oral PPI therapy. 2

Preparation and Administration Protocol

Step	Details
Loading dose	80 mg esomeprazole IV bolus over 15–30 minutes [1,4]
Infusion solution	Mix 240 mg esomeprazole in 240 mL normal saline or 5% dextrose (concentration 1 mg/mL) [1,2]
Continuous infusion	Deliver 8 mg/hour by infusing 8 mL/hour of the prepared solution for exactly 72 hours [1,2,3]
Alternative preparation	160 mg esomeprazole in 200 mL (0.8 mg/mL) infused at 10 mL/hour (also yields 8 mg/hour) [2]

• Administer the loading dose over at least 15 minutes to minimize the risk of infusion-site reactions, including thrombophlebitis. 1, 4
• Infusion-site reactions (mild, transient) occur in approximately 4.3% of patients but rarely require treatment discontinuation. 5
• Consider central venous access if prolonged IV therapy is needed and peripheral access is problematic. 2

Timing and Pre-Endoscopy Considerations

• Start esomeprazole therapy immediately upon presentation, even before endoscopy, to potentially reduce stigmata of recent bleeding. 2, 3
• Do not delay urgent endoscopic intervention while relying solely on PPI therapy—esomeprazole is adjunctive to endoscopic hemostasis, not a replacement. 2, 3
• Consider pre-endoscopy erythromycin to enhance gastric visualization during the procedure. 2, 3

Transition to Oral Therapy

• After completing the 72-hour IV infusion, switch immediately to oral esomeprazole 40 mg twice daily (days 4–14). 1, 2
• From day 15 onward, reduce to oral esomeprazole 40 mg once daily and continue for a total of 6–8 weeks to ensure complete mucosal healing. 1, 2, 3
• Long-term PPI therapy beyond 6–8 weeks is not recommended unless the patient has ongoing NSAID use or persistent Helicobacter pylori infection. 1, 2, 3

Adjunctive Management

• Test all patients for H. pylori infection using biopsy, stool antigen, or urea breath test; provide eradication therapy if positive. 1, 2, 3
• Repeat H. pylori testing after the acute bleeding phase because sensitivity is reduced during active hemorrhage. 2
• Confirm eradication 4–6 weeks after completing antibiotic therapy, as untreated infection raises rebleeding risk to approximately 33% within 1–2 years. 1, 2
• Restart low-dose aspirin within 7 days when cardiovascular benefit outweighs GI risk; combine with PPI rather than clopidogrel alone. 1, 3
• For patients requiring ongoing NSAID therapy, use a COX-2 inhibitor plus PPI to lower GI complication rates. 1, 3

Monitoring and Hospitalization

• Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis, even if clinically stable, to monitor for rebleeding. 2, 3
• Low-risk patients may be discharged within 24 hours. 2
• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. 3

Management of Rebleeding

• If rebleeding occurs, a second endoscopic therapy is the first-line approach. 2
• When endoscopic control fails, consider transcatheter arterial embolization or surgical consultation. 2

Critical Pitfalls to Avoid

• Never use lower doses in high-risk patients—only the high-dose continuous infusion (8 mg/hour) has demonstrated mortality benefit. 6, 2, 3
• Do not discontinue therapy before 6–8 weeks, as premature discontinuation prevents adequate mucosal healing. 2, 3
• Never rely solely on PPI therapy without endoscopic intervention in active bleeding. 2, 3
• Do not infuse esomeprazole too rapidly (< 15 minutes for the bolus), as this increases the risk of thrombophlebitis at the infusion site. 1, 4

Pharmacokinetic and Safety Considerations

• Esomeprazole provides faster and more effective gastric acid control than pantoprazole or omeprazole when administered intravenously. 7, 8
• Varying the infusion rate of esomeprazole 40 mg has little effect on pharmacokinetics, providing flexibility in dosing regimens. 4
• Esomeprazole was well tolerated in clinical trials, with a safety profile similar to oral formulations. 5, 7
• Three deaths occurred in the esomeprazole group versus eight in the placebo group during a large randomized trial (0.8% vs 2.1%, p = 0.22), with only one death during the 72-hour IV treatment phase. 5

Contraindications and Special Populations

• Esomeprazole is approved for pediatric patients 1 month to 17 years of age as an alternative to oral therapy, with weight- and age-based dosing. 9
• No specific contraindications exist for esomeprazole IV drip in adults with upper GI bleeding, but monitor for infusion-site reactions. 5, 4