What situations in the emergency department would warrant administration of intravenous (IV) famotidine (Pepcid) or pantoprazole?

From the Guidelines

In the emergency department, IV pantoprazole is recommended for acute gastrointestinal bleeding, suspected upper GI bleeding, or severe gastroesophageal reflux disease (GERD) with inability to tolerate oral medications, at an initial dose of 80mg IV bolus followed by 8mg/hr continuous infusion for 72 hours, as it provides more potent and longer-lasting acid suppression compared to famotidine 1. The use of IV pantoprazole in these situations is supported by the most recent and highest quality study, which suggests that high-dose proton pump inhibitors, such as pantoprazole, reduce rebleeding, surgical intervention, and mortality following endoscopic hemostasis in patients with bleeding peptic ulcers 1. Some key points to consider when administering IV pantoprazole include:

• The medication works by inhibiting the proton pump directly, reducing gastric acid production and providing more potent and longer-lasting acid suppression compared to famotidine 1.
• IV administration is particularly valuable when patients cannot take oral medications due to vomiting, NPO status, or altered mental status.
• Once the patient stabilizes, transition to oral therapy is recommended as soon as feasible to reduce costs and complications associated with IV access.
• The role of acid suppression in the treatment of peptic ulcer and its complications is well known, and the dosage and duration of PPI administration for the treatment of bleeding peptic ulcer are still a matter of debate 1. It is also important to note that while famotidine may be used in less severe cases or for prophylaxis, pantoprazole is generally preferred for active upper GI bleeding due to its more potent and longer-lasting acid suppression properties 1.

From the FDA Drug Label

In some hospitalized patients with pathological hypersecretory conditions or intractable ulcers, or in patients who are unable to take oral medication, famotidine injection may be administered until oral therapy can be instituted. The recommended dosage for famotrazole injection in adult patients is 20 mg intravenously q 12 h Two studies measured the pharmacodynamic effects of 6 day treatment with intravenous pantoprazole sodium in patients with ZE Syndrome (with and without multiple endocrine neoplasia type I)

• Pathological Hypersecretory Conditions: IV pantoprazole or famotidine may be given in the emergency department for patients with conditions such as Zollinger-Ellison Syndrome.
• Intractable Ulcers: IV pantoprazole or famotidine may be given in the emergency department for patients with intractable ulcers who are unable to take oral medication.
• GERD: There is limited information on the use of IV pantoprazole or famotidine in the emergency department for patients with GERD, and the doses and regimen for parenteral administration in patients with GERD have not been established 2, 3.
• Unable to take oral medication: IV pantoprazole or famotidine may be given in the emergency department for patients who are unable to take oral medication.

From the Research

Situations for IV Pepcid or Pantoprazole in the Emergency Department

• High-risk peptic ulcers: IV proton-pump inhibitors (PPIs) like pantoprazole are indicated for the treatment of high-risk peptic ulcers 4.
• Complicated gastroesophageal reflux: IV PPIs are also used in the treatment of complicated gastroesophageal reflux 4.
• Stress-induced ulcer prophylaxis: IV PPIs can be used for stress-induced ulcer prophylaxis, especially in critically ill patients 5, 4, 6.
• Patients receiving mechanical ventilation: Patients who are mechanically ventilated for more than 48 hours are at high risk for stress-related mucosal disease and may benefit from IV PPIs or histamine 2 receptor antagonists (H2RAs) like Pepcid 5, 7, 6.
• Coagulopathy: Patients with coagulopathy are at increased risk for bleeding and may benefit from IV PPIs or H2RAs 5, 8, 6.

Considerations for Use

• The choice between IV PPIs and H2RAs should be based on individual patient factors, including the risk of bleeding and the presence of other medical conditions 6.
• The use of IV PPIs may be associated with an increased risk of nosocomial pneumonia and other infectious complications 5, 4, 8, 6.
• The dose and duration of IV PPI or H2RA therapy should be carefully considered to minimize the risk of adverse effects 5, 4.