Intermittent Versus Continuous Infusion Dosing of Intravenous Proton Pump Inhibitors for Upper Gastrointestinal Bleeding

Abstract

Background: Proton pump inhibitor (PPI) continuous infusions or intermittent boluses are used for the treatment of upper gastrointestinal bleeding (UGIB). Intermittent boluses are easier to give and are of lower cost without affecting clinical outcomes. Objective: To compare the rate of rebleeding between intermittent bolus and continuous infusion PPI therapy. Methods: We performed a retrospective, multicenter review of patients with UGIB receiving either continuous or intermittent PPI therapy. During the study period, due to drug and supply shortages, each institution implemented policies preferring intermittent PPI bolus therapy. We performed bivariate and multivariable comparisons of the 2 treatment strategies, with the primary outcome of interest being incidence of rebleeding. Additional variables of interest included intensive care unit (ICU) and hospital lengths of stay, discharge disposition, and in-hospital mortality. Results: Compared with intermittent bolus dosing (n = 209), patients receiving continuous infusion PPI (n = 237) were associated with a higher rate of rebleeding (33.8% vs 23.0%; P = 0.012); however, no difference was detected in multivariable analysis: adjusted odds ratio, 1.50 (95% confidence interval, 0.91-2.50). There was no difference in median hospital or ICU length of stay, discharge disposition, or in-hospital mortality. Correlatively, patients receiving continuous infusion therapy were more likely to have liver disease (29.1% vs 20.1%; P = 0.028), alcohol use disorder (28.3% vs 16.3.%; P = 0.003), history of lower gastrointestinal bleeding (6.4% vs 1.9%; P = 0.021), variceal bleeding (6.3 vs 2.4%, P = 0.045), and be admitted to the ICU (65.0% vs 32.5%, P = 0.00). Conclusions: Introduction of intermittent PPI bolus UGIB treatment via change in hospital policy was not associated with higher rates of rebleeding. However, continuous PPI therapy may have been perceived as more effective as it was used more commonly in high-risk patients.

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

“…Although the most recent guidelines advocate intermittent PPI medication, there is no agreement on which PPI agent, dose, or frequency should be used. 16 Our study also showed no significant difference in mortality rate between the intermittent and continuous PPI therapy groups (1 patient [1.7%] vs 3 patients [7.3%], p=0.308). Hsu et al 20 carried out a trial to compare 2 dosages of pantoprazole infusion for peptic ulcer bleeding.…”

“…There was also no change in the length of hospital or ICU stays, discharge disposition, or in-hospital mortality. 16 …”

“…Although the most recent guidelines advocate intermittent PPI medication, there is no agreement on which PPI agent, dose, or frequency should be used. 16 …”

“…There was also no change in the length of hospital or ICU stays, discharge disposition, or in-hospital mortality. 16 Furthermore, in another study, Mahajan carried out a trial in patients with peptic ulcer disease and upper GI bleeding who randomly received pantoprazole (either a continuous or intermittent therapy). Among 118 patients, 7 (5.9%) had rebleeding.…”

Upper GI bleeding in rural Australia: general surgery still alive and well!

“…PPI infusion administration was lacking with only 81% of patients receiving them despite evidence for the use of high‐dose PPI for 72 h to decrease the risk of rebleeding 12 . Although the intermittent intravenous infusion of proton pump inhibitors for UGIB is not associated with higher rates of bleeding, guidelines regarding a standardized bolus and continuous infusion would allow for standardized management of these patients providing a definitive resource for junior doctors initiating management, reducing uncertainty around medication administration, and thereby reducing the time to endoscopy 13 . Additionally, this would streamline clinical audits of these patients with specific treatment parameters.…”