Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

Effect of oral esomeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

BACKGROUND

After endoscopic treatment of bleeding peptic ulcer, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding. The role of oral proton pump inhibitors for these patients is uncertain. The purpose of the present study was to assess whether the use of oral esomeprazole would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.

METHODS

Patients with actively bleeding ulcers or ulcers with non-bleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive esomeprazole (40 mg p.o. twice daily for 3 days) or placebo. The outcome measures studied were recurrent bleeding, blood transfusion requirement, surgery and death.

RESULTS

A total of 70 patients were enrolled, 35 in each group. Bleeding recurred within 30 days in two patients (5.7%) in the esomeprazole group, as compared with three (8.6%) in the placebo group (P = 0.999). Blood transfusion requirement was 2.8 +/- 1.4 units in the esomeprazole group and 2.7 +/- 1.3 units in the placebo group (P = 0.761). Duration of hospitalization was 4.82 +/- 1.8 days in the esomeprazole group and 4.58 +/- 2.7 days in the placebo group (P = 0.792). No patients needed surgery for control of bleeding and no patients died in both groups.

CONCLUSIONS

After successful endoscopic treatment of bleeding peptic ulcer, oral use of esomeprazole might offer no additional benefit on the risk of recurrent bleeding.

Endoscopic Doppler ultrasound versus endoscopic stigmata-directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis

Recurrent bleeding from acute peptic ulcer hemorrhage is problematic. Studies have shown that Doppler ultrasound (DOP-US) is useful in decreasing rebleeding. We analyzed associated costs and outcomes to better define the role of DOP-US versus Conventional (Forrest classification endoscopic stigmata) in the management of acute peptic ulcer bleeding. Two separate decision analyses were constructed. Recurrent bleeding, failed esophagogastroduodenoscopy (EGD) hemostasis, complications, and surgery rates were derived from medical literature. Costs were based on Medicare data. DOP-US is preferred over Conventional in acute peptic ulcer bleeding with average cost savings per patient ranging from 853 dollars (decision-tree modeling) to 1,160 dollars (Monte Carlo simulation). High-dose intravenous proton-pump inhibitors lowered rates of recurrent bleeding for both Conventional and DOP-US, resulting in a lower but still persistent average cost savings per patient for DOP-US (decision-tree modeling = 328 dollars, Monte Carlo simulation = 560 dollars). This decision analyses identified DOP-US as the preferred cost-minimizing strategy in acute peptic ulcer hemorrhage. Results of cost analyses were most dependent on hospitalization costs and recurrent bleeding rates.

A head to head comparison of oral vs intravenous omeprazole for patients with bleeding peptic ulcers with a clean base, flat spots and adherent clots

AIM: To compare the effect of intravenous and oral omeprazole in patients with bleeding peptic ulcers without high-risk stigmata.

METHODS: This randomized study included 211 patients [112 receiving iv omeprazole protocol (Group 1), 99 receiving po omeprazole 40 mg every 12 h (Group 2)] with a mean age of 52.7. In 144 patients the ulcers showed a clean base, and in 46 the ulcers showed flat spots and in 21 old adherent clots. The endpoints were re-bleeding, surgery, hospital stay, blood transfusion and death. After discharge, re-bleeding and death were re-evaluated within 30 d.

RESULTS: The study groups were similar with respect to baseline characteristics. Re-bleeding was recorded in 5 patients of Group 1 and in 4 patients of Group 2 (P = 0.879). Three patients in Group 1 and 2 in Group 2 underwent surgery (P = 0.773). The mean length of hospital stay was 4.6 ± 1.6 d in Group 1 vs 4.5 ± 2.6 d in Group 2 (P = 0.710); the mean amounts of blood transfusion were 1.9 ± 1.1 units in Group 1 vs 2.1 ± 1.7 units in Group 2 (P = 0.350). Four patients, two in each group died (P = 0.981). After discharge, a new bleeding occurred in 2 patients of Group 1 and in 1 patient of Group 2, and one patient from Group 1 died.

CONCLUSION: We demonstrate that the effect of oral omeprazole is as effective as intravenous therapy in terms of re-bleeding, surgery, transfusion requirements, hospitalization and mortality in patients with bleeding ulcers with low risk stigmata. These patients can be treated effectively with oral omeprazole.

Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993-2003

BACKGROUND & AIMS

ANVUGIB is a common reason for hospital admission and has been traditionally associated with a mortality rate of 5%-10%. There have been numerous innovations in the prevention and management of ANVUGIB in recent years, although the effect of these innovations on ANVUGIB incidence and outcomes is unknown.

METHODS

We used the Statistics Canada's Health Person Oriented Information Database [corrected], which contains data characterizing every inpatient hospital admission in Canada between 1993 and 2003. We identified admissions consistent with nonvariceal upper gastrointestinal bleeding using both a broad and narrow ICD-9/ICD-10-based definition. Data were extracted concerning patient demographics, incidence of surgery for complications of upper gastrointestinal bleeding, and overall mortality.

RESULTS

Between 1993 and 2003, ANVUGIB incidence decreased from 77.1 cases to 53.2 per 100,000/y for the broad definition, and from 52.4 to 34.3 cases per 100,000/y for the narrow definition. ANVUGIB incidence rose slightly in 2000, coincident with the introduction of COX-2 inhibitors. The proportion of ANVUGIB subjects requiring surgical intervention declined over the 10 years from 7.1% to 4.5%, although the rate of decline did not increase after the introduction of intravenous proton pump inhibitors (IV PPIs). The mortality rate remained steady at approximately 3.5%.

CONCLUSIONS

The incidence of ANVUGIB and the need for operative intervention has been steadily declining since 1993. ANVUGIB-associated mortality remained constant, although at a rate lower than traditionally reported. The impact of IV PPIs on mortality and operative intervention on a population-wide basis is likely minimal.

Upper gastrointestinal bleeding

PURPOSE OF REVIEW

This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care.

RECENT FINDINGS

In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions.

SUMMARY

This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?

Pre-endoscopic proton pump inhibitor therapy reduces recurrent adverse gastrointestinal outcomes in patients with acute non-variceal upper gastrointestinal bleeding

BACKGROUND

Proton pump inhibitors (PPIs) following endoscopic haemostasis reduce rebleeding rates in patients with high-risk acute non-variceal upper gastrointestinal bleeding. Many advocate the use of PPIs prior to endoscopy, although its incremental benefit is unproven.

AIM

To determine if providing PPIs before endoscopy reduces adverse gastrointestinal outcomes in acute non-variceal upper gastrointestinal bleeding patients.

METHODS

We performed a retrospective review to identify patients presenting to two tertiary care centres with acute non-variceal upper gastrointestinal bleeding between 1999 and 2004. Subjects receiving PPI therapy before endoscopy were compared with those not receiving pre-endoscopic PPI therapy. The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality, readmission within 30 days for acute non-variceal upper gastrointestinal bleeding).

RESULTS

385 patients were included in our study [132 (12 intravenous/120 po) pre-endoscopic PPI vs. 253 no pre-endoscopic PPI]. Patients receiving pre-endoscopic PPI therapy were significantly less likely to develop adverse outcomes compared with those not given pre-endoscopic PPIs (25% vs. 13%, P = 0.005). Rebleeding, upper gastrointestinal surgery, mortality and length of hospital stay were also significantly lower in patients receiving pre-endoscopic PPI.

CONCLUSIONS

The use of PPIs before endoscopy significantly reduces the risk of developing adverse gastrointestinal outcomes in patients with acute non-variceal upper gastrointestinal bleeding. Future studies are required to better characterize this relationship.

The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data

BACKGROUND

Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness in nonvariceal upper-GI bleeding (NVUGIB). However, there is little information regarding clinical and process determinants that affect the time from onset of bleeding to performance of the endoscopy.

OBJECTIVE

The aim of this study was to identify factors that predict time to endoscopy in patients with new onset NVUGIB.

DESIGN

Linear regression models were constructed with time between triage (outpatients) or onset of bleeding (inpatients) and the performance of endoscopy.

SETTING

The RUGBE is a nationwide, multicenter database collected for the purpose of obtaining descriptive data on patients with NVUGIB.

PATIENTS

The study population consisted of 1500 patients (89.6%) who underwent gastroscopy within 48 hours.

RESULTS

Median time to endoscopy was 12 hours (95% CI 11.0, 13.0). Endoscopy after working hours (regression coefficient [beta] -3.52; 95% CI -5.47, -1.58), availability of an endoscopy nurse on-call for the procedure (beta -2.48; 95% CI -3.83, -1.14), and admission to a hospital unit were associated with a shorter interval to endoscopy. In contrast, the presence of chest pain (beta 3.65; 95% CI 1.64, 5.67) or dyspnea (beta 2.79; 95% CI 1.10, 4.48), absence of gross blood on rectal examination (beta 2.20; 95% CI 0.69, 3.71), and inpatient status at onset of bleeding (beta 14.6; 95% CI 8.70, 20.4) were independent predictors of a delayed endoscopy. Subgroup analysis showed that actual time intervals as well as independent predictors of time until endoscopy differed between inpatients and outpatients.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

The timing of endoscopy in patients with NVUGIB is dependent on both clinical and process parameters, which differ between inpatient and outpatient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy, which is currently recommended for improved patient outcomes.

Implementation of an Algorithm for Intravenous Pantoprazole: Impact on Prescription Compliance in Quebec University Hospitals

Background:

Intravenous pantoprazole is used at Centre Hospitalier de l'Université de Montréal (CHUM) for the adjuvant treatment of nonvariceal upper gastrointestinal bleeding (UGB) and for inhibiting acid secretion among patients unable to tolerate oral intake (NPO). Since it was added to the CHUM formulary, the use of intravenous pantoprazole has steadily increased, and at times it has been used without endoscopic documentation of a nonvariceal UGB or even when the patient could have received a proton pump inhibitor orally.

Objective:

To assess the impact of an algorithm for intravenous pantoprazole on prescription compliance.

Methods:

Using a pre–post intervention specification, the use of pantoprazole was audited on a retrospective (January 1, 2002, to April 30, 2002) and prospective (January 1, 2003, to April 30, 2003) basis. We reviewed the medical records of all patients having received intravenous pantoprazole during these periods, assessing the compliance of prescriptions as specified by the algorithm. Cost of therapy and the step-down regimen were also reviewed.

Results:

In total, 150 patients were identified in the retrospective phase and 109patients in the prospective phase. The subjects were organized into 2 groups: UGB and NPO. In the UGB group, rates of compliance with indication, dose, and duration of treatment in the retrospective phase were 8.8%, 76.5%, and 58.8%, respectively; the corresponding rates for the prospective phase were 26.5% (p < 0.01), 80.9% (p = 0.53), and 69.1% (p = 0.78), respectively. The total rates of compliance (including indication, dose, and duration) were 4.4% in the retrospective phase and 11.8% in the prospective phase (p = 0.12). In the NPO group, the rate of compliance at the initiation of pantoprazole was 42.7% in the retrospective phase and 36.6% in the prospective phase (p = 0.51). The cost of noncompliance with the indication in the UGB group was estimated at $12 270 CDN (in the retrospective phase) and $7829 (in the prospective phase). In the NPO group, the cost figures were $8048 (retrospective phase) and $5929 (prospective phase).

Conclusions:

This study demonstrates that intravenous pantoprazole is being used in a suboptimal manner in our institution. Despite explicit criteria for use, in the prospective phase, we observed only 11.8% total compliance in the UGB group and 36.6% compliance at the initiation of pantoprazole in the NPO group. Even though these results were not statistically significant, in the prospective phase, we saw improvement in most compliance rates.

To establish the efficacy of PPI therapy for ulcer bleeding in the United States, do we need more patients or more PPI [corrected]

Proton pump inhibitor (PPI) therapy is widely used in the management of patients with ulcer bleeding. However, most randomized controlled trials (RCTs) have been conducted outside of the United States. Jensen and colleagues have conducted the first United States-based RCT to compare a PPI with an H(2)-receptor antagonist following appropriate endoscopic hemostatic treatment for patients with ulcer bleeding. Unfortunately, the trial had to be discontinued prematurely because of problems with enrolment. There was a statistically nonsignificant difference in rebleeding rates between the two treatment arms. A type II statistical error probably explains this apparent lack of efficacy. However, U.S. patients may also require higher doses of PPI for adequate control of intragastric acidity.

Continuous infusion of pantoprazole versus ranitidine for prevention of ulcer rebleeding: a U.S. multicenter randomized, double-blind study

OBJECTIVES

No North American randomized study has compared ulcer rebleeding rates after endoscopic hemostasis in high-risk patients treated with high-dose intravenous (IV) proton pump inhibitors (PPIs) or IV histamine-2 receptor antagonists. Our hypothesis was that ulcer rebleeding with IV pantoprazole (PAN) would be lower than with IV ranitidine (RAN).

METHODS

This was a multicenter, randomized, double-blind, U.S. study. Patients with bleeding peptic ulcers and major stigmata of hemorrhage had endoscopic hemostasis with thermal probes with or without epinephrine injection, then were randomly assigned to IV PAN 80 mg plus 8 mg/h or IV RAN 50 mg plus 6.25 mg/h for 72 h, and subsequently had an oral PPI (1/day). Patients with signs of rebleeding had repeat endoscopy. Rebleeding rates up to 30 days were compared in an intention-to-treat analysis.

RESULTS

The study was stopped early because of slow enrollment (total N = 149, PAN 72, RAN 77). Demographics, APACHE II scores, ulcer type/location, stigmata, and hemostasis used were similar. The 7- and 30-day rebleeding rate was 6.9% (5 of 72 patients) with PAN and 14.3% (11 of 77) for RAN (p= 0.19). Rebleeds occurred within 72 h in 56% and between 4 and 7 days in 44% of patients. The 30-day mortality rate was 4%. Nonbleeding severe adverse events were more common in the RAN than in the PAN group (14 [18.1%]vs 7 [9.7%], p= 0.16).

CONCLUSIONS

Because of the small sample size of this study, there was an arithmetic but not significant difference in ulcer rebleeding rates.

Effect of frequent dosing of an oral proton pump inhibitor on intragastric pH

BACKGROUND

Treatment with a continuous i.v. proton pump inhibitor is presumed to promote clot formation and stability by sustaining intragastric pH > or = 6.

AIM

We postulated that very frequent oral dosing of proton pump inhibitors should simulate i.v. infusion and achieve similar pH control.

METHODS

Twenty healthy volunteers were stratified by Helicobacter pylori status (10 positive; 10 negative) and had determination of CYP2C19 status. After an overnight fast, an intragastric pH probe was placed. Subjects received 120 mg of lansoprazole at 8 am and 30 mg every 3 h until 8 pm. Intragastric pH was measured over 24 h, and lansoprazole plasma concentrations were determined at five time points.

RESULTS

Intragastric pH was > or = 6 for 41% (95% CI: 30-53%) of the 15-h period from 8 am-11 pm and 46% (95% CI: 35-56%) of the 24-h period (8-8 am). The mean proportion of patients with pH > or = 6 was not significantly different in H. pylori-positive vs. negative patients. Only 25% of subjects sustained pH > or = 6 for at least 60% of the 15-h period, and 35% had a sustained pH > or = 6 for at least 60% of the 24-h period.

CONCLUSIONS

A dose of 120 mg of oral lansoprazole followed by standard 30 mg doses of lansoprazole every 3 h did not reliably sustain pH at the desired level of 6.

Management der Ulkusblutung

Bleeding peptic ulcers are responsible for about half of all upper gastrointestinal hemorrhages, one of the most frequent gastroenterological emergencies. In its pathogenesis, infection with Helicobacter pylori and the use of ulcerogenic drugs play a dominant role. Endoscopy has to be performed urgently when a decline in hemoglobin and/or hemodynamic instability occurs. The indications for local endoscopic therapy depend on the Forrest criteria, which include bleeding and the presence or absence of a blood clot or visible vessel. Local endoscopic therapy comprises injections and mechanical or thermal procedures. The efficacy of these procedures has been demonstrated. Additionally, proton pump inhibitors are administered. The prognosis for bleeding ulcers depends on the endoscopic findings as well as the age and comorbidity of the patients.

Review article: acid-related disease--what are the unmet clinical needs?

Proton pump inhibitors have dramatically improved the management options available for patients with acid-related disorders. In patients with gastro-oesophageal reflux disease, currently available proton pump inhibitors provide an excellent outcome for the majority; however, they do not provide optimal pH control in many. Proton pump inhibitors co-therapy reduces, but does not eliminate, the risk of gastrointestinal ulcers and complications in patients taking non-steroidal anti-inflammatory drugs, while in patients with upper gastrointestinal bleeding, it may be difficult to reach and maintain the current therapeutic target of intragastric pH of 6-7. This article reviews the effectiveness of current antisecretory therapy in these three acid-related diseases and areas of unmet clinical need. The potential role of a proton pump inhibitor with an extended duration of action and enhanced acid control from a single daily dose, particularly improved control at night, is discussed. Finally, therapy that could be administered without regard to time of day and/or food intake would offer dosing flexibility and thus have a positive effect on patients' compliance.

Opportunities for Optimizing Pantoprazole Therapy in Patients with Acute Upper Gastrointestinal Bleeding

Purpose

To evaluate the appropriateness of intravenous (IV) pantoprazole in subjects presenting with signs suspicious of acute gastrointestinal bleeding (AGIB) and to identify opportunities for optimizing its use.

Methods

Retrospective health record review of subjects receiving IV pantoprazole for suspected or confirmed AGIB was conducted at two affiliated teaching hospitals.

Results

Of the 175 subjects enrolled, 157 (90%) received a diagnostic endoscopy. The median time to endoscopy was 18.5 hours, and the median time to start pantoprazole was 6.9 hours. Thirty-seven subjects (21%) did not receive the appropriate pantoprazole dose of 80 mg bolus followed by 8 mg/h infusion, and 22 high-risk subjects (33%) received less than 60 hours of IV pantoprazole. The median duration of pantoprazole following endoscopy for low-risk subjects was 21.1 hours.

Conclusion

Opportunities to optimize the use of IV pantoprazole include initiating therapy quickly at the appropriate dosing regimen, continuing the infusion for 72 hours in patients with high-risk bleeds, and discontinuing the infusion promptly once a high-risk AGIB is ruled out.

Dose-response evaluation of the antisecretory effect of continuous infusion intravenous lansoprazole regimens over 48 h

BACKGROUND

Attainment of intragastric pH < 6.0 may require high-dose continuously infused proton pump therapy.

AIM

To assess the pharmacokinetic and pharmacodynamic dose-responses of continuous infusion regimens of lansoprazole.

METHODS

Healthy adult subjects were assigned to lansoprazole 60-mg intravenous bolus, followed by 6-mg/h continuous infusion; a 90-mg intravenous bolus followed by 6-, 7.5-, or 9-mg/h continuous infusion; or placebo.

RESULTS

Mean intragastric pH values for lansoprazole regimens ranged from 4.8 to 5.2 (0-24 h), 5.5 to 6.0 (>24 to 48 h) and 5.2 to 5.6 (0-48 h). Within these three intervals, the percentages of time intragastric pH exceeded 4, 5 and 6 ranged from 65% to 96%, 54% to 88% and 30% to 61% respectively. Pharmacokinetic parameters were dose-independent with steady-state plasma concentrations achieved within 6-12 h postdose and maintained over 48 h. The mean systemic clearance of lansoprazole was lower in CYP2C19 heterozygous metabolizers than in homozygous extensive metabolizers (9.2 vs. 16.5 L/h), with substantial variability resulting in overlapping ranges of clearance values for both subpopulations. All lansoprazole regimens were well-tolerated.

CONCLUSIONS

Lansoprazole administered as a 60-mg intravenous bolus followed by 6-mg/h continuous infusion produced intragastric pH effects comparable with those of higher dosage regimens.

Pantoprazole infusion as adjuvant therapy to endoscopic treatment in patients with peptic ulcer bleeding: prospective randomized controlled trial

BACKGROUND AND AIM

Following successful endoscopic therapy in patients with peptic ulcer bleeding, rebleeding occurs in 20% of patients. Rebleeding remains the most important determinant of poor prognosis. We investigated whether or not administration of pantoprazole infusion would improve the outcome in ulcer bleeding following successful endoscopic therapy.

METHODS

In this double-blind, placebo-controlled, prospective trial, patients who had gastric or duodenal ulcers with active bleeding or non-bleeding visible vessel received combined endoscopy therapy with injection of epinephrine and heater probe application. Patients who achieved hemostasis were randomly assigned to receive pantoprazole (80 mg intravenous bolus followed by an infusion at a rate of 8 mg per hour) or placebo for 72 h. The primary end-point was the rate of rebleeding.

RESULTS

Rebleeding was lower in the pantoprazole group (8 of 102 patients, 7.8%) than in the placebo group (20 of 101 patients, 19.8%; P = 0.01). Patients in the pantoprazole group required significantly fewer transfusions (1 +/- 2.5 vs 2 +/- 3.3; P = 0.003) and days of hospitalization (5.6 +/- 5.3 vs 7.7 +/- 7.3; P = 0.0003). Rescue therapies were needed more frequently in the placebo group (7.8% vs 19.8%; P = 0.01). Three (2.9%) patients in the pantoprazole group and eight (7.9%) in the placebo group required surgery to control their bleeding (P = 0.12). Two patients in the pantoprazole group and four in the placebo group died (P = 0.45).

CONCLUSION

In patients with bleeding peptic ulcers, the use of high dose pantoprazole infusion following successful endoscopic therapy is effective in reducing rebleeding, transfusion requirements and hospital stay.

Lansoprazole regimens that sustain intragastric pH > 6.0: an evaluation of intermittent oral and continuous intravenous infusion dosages

BACKGROUND

Orally and intravenously administered proton pump inhibitors have been shown to reduce rebleeding rates, surgery and transfusion requirement.

AIM

To compare lansoprazole intravenous and orally disintegrating tablet (Prevacid SoluTab) regimens with a pantoprazole intravenously administered regimen in sustaining intragastric pH >6.0.

METHODS

Two similarly designed three-way, randomized crossover studies each enrolled 36 Helicobacter pylori-negative healthy volunteers. Study 1 regimens included intravenously administered bolus followed by 24-h continuous infusion (lansoprazole 90 mg, 6 mg/h; lansoprazole 120 mg, 6 mg/h; pantoprazole 80 mg, 8 mg/h). Study 2 regimens included intravenous bolus followed by lansoprazole orally disintegrating tablet or intravenous continuous infusion for 24 h (lansoprazole 90 mg, lansoprazole orally disintegrating tablet 60 mg every 6 h; lansoprazole 120 mg, 9 mg/h; pantoprazole 80 mg, 8 mg/h). Percentage of time pH >6.0 was assessed with 24-h intragastric pH monitoring.

RESULTS

All regimens produced comparable gastric acid suppression. In both studies, regimens superior to pantoprazole included lansoprazole 90 mg, 6-mg/h; lansoprazole 90 mg, lansoprazole orally disintegrating tablet 60 mg q.d.s. and lansoprazole 120 mg, 9 mg/h (P < or = 0.013). The lansoprazole 120-mg, 6-mg/h regimen (P = 0.082) was not superior to pantoprazole in percentage of time intragastric pH >6.0. Mild reaction at the intravenous injection site was the most frequently reported adverse event.

CONCLUSIONS

The intravenous bolus and continuously infused lansoprazole or intravenous bolus and intermittent lansoprazole orally disintegrating tablet regimens are as effective as intravenous pantoprazole in sustaining intragastric pH >6.0.

Role of intravenous omeprazole in patients with high-risk peptic ulcer bleeding after successful endoscopic epinephrine injection: a prospective randomized comparative trial

BACKGROUND

Epinephrine injection is the most common endoscopic therapy for peptic ulcer bleeding. Controversy exists concerning the optimal dose of proton pump inhibitors (PPI) for patients with bleeding peptic ulcers after successful endoscopic therapy. The objective of this study was to determine the optimal dose of PPI after successful endoscopic epinephrine injection in patients with bleeding peptic ulcers.

METHODS

A total of 200 peptic ulcer patients with active bleeding or nonbleeding visible vessels (NBVV) who had obtained initial hemostasis with endoscopic injection of epinephrine were randomized to receive omeprazole 40 mg infusion every 6 h, omeprazole 40 mg infusion every 12 h or cimetidine (CIM) 400 mg infusion every 12 h. Outcomes were checked at 14 days after enrollment.

RESULTS

Rebleeding episodes were fewer in the group with omeprazole 40 mg infusion every 6 h (6/67, 9%) as compared with that of the CIM infusion group (22/67, 32.8%, p < 0.01). The volume of blood transfusion was less in the group with omeprazole 40 mg every 6 h than in those groups with omepraole 40 mg infusion every 12 h (p= 0.001) and CIM 400 mg infusion every 12 h (p < 0.001). The hospital stay, number of patients requiring urgent operation, and death rate were not statistically different among the three groups.

CONCLUSION

A combination of endoscopic epinephrine injection and a large dose of omeprazole infusion is superior to combined endoscopic epinephrine injection with CIM infusion for preventing recurrent bleeding from peptic ulcers with active bleeding or NBVV.

[A case of postoperative pulmonary metastasis of breast cancer treated with docetaxel and cyclophosphamide therapy]

A 55-year-old woman underwent a partial breast resection in our hospital for breast cancer in May 2002. For adjuvant therapy, she received cyclophosphamide, pirarubicin and 5-FU infusion a total of 6 times, and anastrozole. Then, in May of 2004, an abnormal shadow was detected on her of chest X-ray. After CT scan we diagnosed multiple pulmonary metastasis of breast cancer. We used combination therapy of docetaxel 60 mg/m(2) and cyclophosphamide 500 mg/m(2). After 9 months, pulmonary metastasis disappeared on her CT scan. During chemotherapy, she showed no major side effect.

Proton pump inhibitor treatment for acute peptic ulcer bleeding

BACKGROUND

Randomised controlled trials (RCTs) evaluating the clinical effect of proton pump inhibitors (PPIs) in peptic ulcer (PU) bleeding yield conflicting results.

OBJECTIVES

To evaluate the efficacy of PPIs in acute bleeding from PU using evidence from RCTs.

SEARCH STRATEGY

We searched CENTRAL, The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to November 2004), EMBASE (1980 to November 2004), proceedings of major meetings to November 2004, and reference lists of articles. We contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

RCTs of PPI treatment (oral or intravenous) compared with placebo or H(2)-receptor antagonist (H(2)RA) in acute bleeding from PU.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently, assessed study validity, summarised studies and undertook meta-analysis. The influence of study characteristics on the outcomes was examined by subgroup analyses and meta-regression.

MAIN RESULTS

Twenty-four RCTs comprising 4373 participants in total were included. Statistical heterogeneity was found among trials for rebleeding (P = 0.04), but not for all-cause mortality (P = 0.24) or surgery (P = 0.45). There was no significant difference in all-cause mortality rates between PPI and control treatment; pooled rates were 3.9% on PPI versus 3.8% on control (odds ratio (OR) 1.01; 95% CI 0.74 to 1.40). PPIs significantly reduced rebleeding compared to control; pooled rates were 10.6% with PPI versus 17.3% with control treatment (OR 0.49; 95% CI 0.37 to 0.65). PPI treatment significantly reduced surgery compared with control; pooled rates were 6.1% on PPI versus 9.3% on control (OR 0.61; 95% CI 0.48 to 0.78). There was no evidence to suggest that results on mortality and rebleeding were dependent on study quality, route of PPI administration, type of control treatment or application of initial endoscopic haemostatic treatment. PPIs significantly reduced surgery compared with placebo but not when compared with H(2)RA. There was no evidence to suggest that study quality, route of PPI administration or application of initial endoscopic haemostatic treatment influenced results on surgery. PPI treatment appeared more efficacious in studies conducted in Asia compared to studies conducted elsewhere. All-cause mortality was reduced only in Asian studies; reductions in rebleeding and surgery were quantitatively greater in Asian studies. Among patients with active bleeding or non-bleeding visible vessel, PPI treatment reduced mortality (OR 0.53; 95% CI 0.31 to 0.91), rebleeding and surgery.

AUTHORS' CONCLUSIONS

PPI treatment in PU bleeding reduces rebleeding and surgery compared with placebo or H(2)RA, but there is no evidence of an overall effect on all-cause mortality.

A comparison of oral omeprazole and intravenous cimetidine in reducing complications of duodenal peptic ulcer

Background

Gastrointestinal bleeding is a common problem and its most common etiology is peptic ulcer disease. Ulcer rebleeding is considered a perilous complication for patients. To reduce the rate of rebleeding and to fasten the improvement of patients' general conditions, most emergency departments in Iran use H2-blockers before endoscopic procedures (i.e. intravenous omeprazole is not available in Iran). The aim of this study was to compare therapeutic effects of oral omeprazole and intravenous cimetidine on reducing rebleeding rates, duration of hospitalization, and the need for blood transfusion in duodenal ulcer patients.

Methods

In this clinical trial, 80 patients with upper gastrointestinal bleeding due to duodenal peptic ulcer and endoscopic evidence of rebleeding referring to emergency departments of Imam and Sina hospitals in Tabriz, Iran were randomly assigned to two equal groups; one was treated with intravenous cimetidine 800 mg per day and the other, with 40 mg oral omeprazole per day.

Results

No statistically significant difference was found between cimetidine and omeprazole groups in regards to sex, age, alcohol consumption, cigarette smoking, NSAID consumption, endoscopic evidence of rebleeding, mean hemoglobin and mean BUN levels on admission, duration of hospitalization and the mean time of rebleeding. However, the need for blood transfusion was much lower in omeprazole than in cimetidine group (mean: 1.68 versus 3.58 units, respectively; p < 0.003). Moreover, rebleeding rate was significantly lower in omeprazole group (15%) than in cimetidine group (50%) (p < 0.001).

Conclusion

This study demonstrated that oral omeprazole significantly excels intravenous cimetidine in reducing the need for blood transfusion and lowering rebleeding rates in patients with upper gastrointestinal bleeding. Though not statistically significant (p = 0.074), shorter periods of hospitalization were found for omeprazole group which merits consideration for cost minimization.

Current management of peptic ulcer bleeding

Peptic ulcer bleeding is a common and potentially fatal condition. It is best managed using a multidisciplinary approach by a team with medical, endoscopic and surgical expertise. The management of peptic ulcer bleeding has been revolutionized in the past two decades with the advent of effective endoscopic hemostasis and potent acid-suppressing agents. A prompt initial clinical and endoscopic assessment should allow patients to be triaged effectively into those who require active therapy, versus those who require monitoring and preventative therapy. A combination of pharmacologic and endoscopic therapy (using a combination of injection and thermal coagulation) offers the best chance of hemostasis for those with active bleeding ulcers. Surgery, being the most effective way to control bleeding, should be considered for treatment failures. The choice between surgery and repeat endoscopic therapy should be based on the pre-existing comorbidities of the patient and the characteristics of the ulcer.

Possible Interethnic Differences in Omeprazole Pharmacokinetics

BACKGROUND AND OBJECTIVE

Considerable ethnic differences have been reported in the incidence of the poor metaboliser (PM) genotype of cytochrome P450 (CYP) 2C19. The frequency of this genotype was found to be much higher in Oriental persons (13-23%) than in American or European populations (3-5%). There are, however, no valid data published for Arabic subjects. The present study was conducted to evaluate pharmacokinetic parameters of omeprazole after a single dose in healthy Jordanian Arabic subjects and to compare the results with data published for other populations.

METHODS

Seventy-four healthy male Jordanian Arabic volunteers contributed to the study, which was performed at Al Essra Hospital in Amman, Jordan. After an overnight fast, omeprazole was administered as a single Losec 20mg capsule. A total of 20 blood samples were collected over a 10-hour period after administration. Omeprazole pharmacokinetic parameters were determined from the plasma concentration-time profiles using the WinNonlin software. Kolmogorov-Smirnov's test and probit plots of omeprazole area under the plasma concentration-time curve (AUC) data were used to analyse the frequency distribution of phenotypic data.

RESULTS

The mean pharmacokinetic parameters and their corresponding coefficient of variation (CV%) for peak plasma concentration (Cmax), AUC from time zero to infinity (AUCinfinity), time to reach Cmax (tmax), apparent oral clearance (CL/F) and elimination half-life (t(1/2)) were 314.96 ng/mL (56%), 923.2 ng . h/mL (108.6%), 2.1h (44%), 0.66 L/h/kg (92%) and 1.5 h (56.6%), respectively. Interindividual differences in the current study were high for all pharmacokinetic parameters, yet comparable to CVs reported in nonphenotyped subjects identified within other ethnic groups (40.3-159% for AUC and 39-48.2% for Cmax). The frequency distribution of all parameters, particularly the AUC, was shown to be trimodal. This has proposed the presence of three distinct phenotypes, designated as extensive metabolisers (EMs), slow-extensive metabolisers (SEMs), and PMs, with corresponding frequency of 36.5%, 39.2% and 24.3%, respectively. After stratification, the relative mean AUCs of omeprazole in EMs, SEMs and PMs were 1 : 2.7 : 9.3 (all p < 0.001). Accordingly, the CL/F of omeprazole showed a ratio of 9.8 : 3.6 : 1 for three phenotype groups, respectively. For other pharmacokinetic parameters including Cmax, t1/2, AUC normalised for bodyweight (AUCN), Cmax/dose and AUC/dose, there were also significant differences between the three groups.

CONCLUSIONS

The current pharmacokinetic study revealed that the majority of the Jordanian Arabics seemed to be more properly classified within the EM phenotype. More specifically, the observed metabolic rates of heterozygous and homozygous Jordanian Arabic EMs were more comparable to those of Caucasian EMs than Oriental EMs. Consequently, higher dosage requirements can be expected among most of the Jordanian Arabics. Yet, the incidence of PMs is significant and they seemed to exhibit a similar pharmacokinetic pattern to Chinese PMs in terms of long-term exposure (clearance and AUC) as well as short-term exposure (Cmax) parameters, after adjustment for dose and bodyweight. Therefore, further clinical application of CYP2C19 polymorphism is anticipated in Jordanian Arabic mixed population, particularly if long-term use of omeprazole is intended.

Late-onset life threatening hemorrhage of omeprazole-resistant duodenal ulcer managed by interventional radiology: report of a case

A 67-year-old diabetic man was emergently hospitalized in our department because of a huge duodenal ulcer without visible vessels. Despite of intravenous administration of 40 mg omeprazole and fasting with intravenous nutritional support, endoscopically unmanageable massive bleeding occurred on the 8th hospital day. Emergent angiography showed extravasation of contrast media from a duodenal branch of the proper hepatic artery, and superselective arterial embolization was successfully achieved. The patient recovered from the hemorrhagic shock and underwent subsequent successful surgery. Analysis of CYP2C19 enzyme genotype indicated the patient was a homozygous extensive metabolizer, considered a poor responder for omeprazole treatment.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: a two-year survey

AIM

To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.

METHODS

All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.

RESULTS

Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.

CONCLUSION

Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Review article: the role of antisecretory therapy in the management of non-variceal upper gastrointestinal bleeding

Non-variceal, upper gastrointestinal bleeding accounts for 300,000 hospitalizations annually in the US and the risk of rebleeding and mortality remain high. The aim of this study was to review the incidence and causes of non-variceal upper gastrointestinal haemorrhage, criteria for early discharge, risk stratification and intravenous vs. oral proton-pump inhibitor use. Peptic ulcer disease accounts for 45% of all admissions for upper gastrointestinal bleeding. Clinical and endoscopic predictors of adverse outcome have been identified. The Rockall scoring system identifies patients who can be considered for early discharge after endoscopy. Evidence supports the use of intravenous proton-pump inhibitor therapy for patients with bleeding ulcers associated with high-risk stigmata. Patients who are clinically stable and in whom upper endoscopy has shown an ulcer with a clean base or a flat pigmented spot have a low risk for rebleeding and may be discharged early on oral proton-pump inhibitor therapy. Proton-pump inhibitor treatment reduces ulcer rebleeding but does not affect overall mortality. In the US, most patients with ulcer bleeding have low-risk stigmata, and thus, can be treated with oral proton-pump inhibitors and discharged early.

The effect of regular and high doses of omeprazole on the intragastric acidity in patients with bleeding peptic ulcer treated endoscopically: a clinical trial with continuous intragastric pH monitoring

OBJECTIVE

In peptic ulcer bleeding (PUB), pH level >4 is considered necessary to prevent dissolving of a formed fibrin clot. The effect of regular or high doses of omeprazole on the intragastric pH in patients with acute PUB was studied.

METHODS

In our earlier study, after endoscopic therapy, PUB patients were randomized to receive a regular dose of intravenous omeprazole (20 mg; i.e. 60 mg/3 days) or a high dose of omeprazole (80 mg bolus + 8 mg/h; i.e. 652 mg/3 days). Of these 142 analysed and reported patients, 13 PUB patients also had intragastric pH monitoring for these 3 days; seven of these patients had a regular dose and six received a high dose of omeprazole.

RESULTS

The mean 24-h intragastric pH (regular versus high dose) on day 1 was 4.9 +/- 1.6 versus 6.3 +/- 0.5 (P = 0.035), on day 2 was 4.9 +/- 1.8 versus 6.7 +/- 0.3 (P = 0.001), and on day 3 was 5.7 +/- 1.1 versus 6.7 +/- 0.5 (P = NS). The medians of the intragastric pH were 6 versus 6.5 (P = 0.082) on day 1, 5.8 versus 6.8 (P = 0.001) on day 2, and 6.2 versus 6.8 (P = 0.17) on day 3. The proportion of time when pH <4 on day 1 was 29.2 +/- 34.1 versus 5.4 +/- 5.7% (P = NS).

CONCLUSIONS

A regular dose of omeprazole raises the mean and median 24-h intragastric pH >4 in patients with PUB. This reduction in the acidity together with endoscopic therapy is probably sufficient to maintain haemostasis. A high dose of omeprazole keeps the pH almost constantly >6.

Inappropriate use of intravenous pantoprazole: extent of the problem and successful solutions

BACKGROUND & AIMS

Indications for intravenous proton pump inhibitors (IV PPI) include upper gastrointestinal bleeding (UGIB) from peptic ulcer disease with high-risk stigmata and patients receiving nothing by mouth (NPO). The objectives were to assess the extent of errors in indications for IV PPI use and to determine whether multidisciplinary interventions could improve IV PPI use and costs.

METHODS

Part 1: Patients prescribed IV PPI during a period of 4 months were divided into 2 settings, UGIB or non-UGIB. The setting-specific appropriateness of the IV PPI indication and dosing regimen was determined. Part 2: Patients prescribed IV PPI before and after multidisciplinary interventions (educating physicians, a computerized dose template, pharmacists altering IV PPI orders in non-UGIB patients who were not NPO, and recommending a GI consult when a continuous infusion was ordered) were studied. Incidence of prescribing errors, IV PPI costs, and potential confounders were compared.

RESULTS

Part 1: Only 50% of UGIB (n = 145) patients received IV PPI for an appropriate indication. Both indication and dosing regimen were appropriate in 21%. In the non-UGIB group (n = 95), 33% were truly NPO; 51% had a correct dosing frequency. Part 2: The postintervention (n = 105) group (vs the preintervention group, n = 113) showed a significant absolute reduction in the degree of inappropriate indication in the UGIB (26%; 95% confidence interval [CI], 10%-42%; P < .0001) and in the non-UGIB (41%; 95% CI, 24%-58%; P < .0001) subgroups. However, a greater improvement in underspending than overspending meant that overall costs were unchanged.

CONCLUSIONS

IV PPI was frequently prescribed inappropriately and incorrectly; simple maneuvers resulted in reductions in errors.

Inadequate use of acid-suppressive therapy in hospitalized patients and its implications for general practice

Acid-suppressive therapy (AST) is largely prescribed in both hospital and general practice setting but few data are available on appropriateness of AST use in hospitalized patients and its fallout on prescribing in general practice. We assessed AST in patients consecutively admitted to an internal medicine department to determine the type and timing of prescription and indication for use according to widely accepted guidelines. Prescriptions were rated as indicated, acceptable, or not indicated. Overall, 58.7% of 834 admitted patients received AST, mainly proton pump inhibitors. The prescriptions were indicated in 50.1% of patients, not indicated in 41.5%, and acceptable in 6.5%. The main reason for inappropriate use was prophylaxis in low-risk patients (64.8%). On admission, 35.7% of 112 patients already on AST were judged to receive inappropriate prescription; of 348 patients discharged on AST, overuse was identified in 38.5%. No significant difference was observed for inappropriate use at admission, during hospitalization, and at discharge. In 64 inpatients (7.7%) AST, although indicated, mainly for ulcer prophylaxis in high-risk patients, was not prescribed. In conclusion, AST is substantially over-used in both hospital and general practice settings, mainly for ulcer prophylaxis in low-risk patients. On the other hand, AST is underused in a small, but not negligible proportion of high-risk patients.

Proton pump inhibitor formulary considerations in the acutely ill. Part 2: Clinical efficacy, safety, and economics

OBJECTIVE

To review, using an evidence-based approach, the clinical efficacy, safety, and cost-effectiveness of proton pump inhibitors (PPIs) for treatment of common acid peptic disorders in the acutely ill and provide clinicians with guidance when making hospital formulary decisions with this class of agents.

DATA SOURCES

MEDLINE (1966-May 2005) and the Cochrane Library databases were searched using the key words proton pump inhibitor, acid suppression, peptic ulcer disease, gastrointestinal bleeding, stress ulcer prophylaxis, critical care, safety, and cost-effectiveness. Bibliographies of cited references were reviewed, and a manual search of abstracts from recent gastroenterology, critical care, and surgery scientific meetings was completed.

STUDY SELECTION AND DATA EXTRACTION

All articles identified from the data sources were evaluated, and all information deemed relevant was included for this review.

DATA SYNTHESIS

PPIs have become a mainstay for acute acid suppression in hospitalized patients. Various commercially available PPI products are available either enterally or parenterally for administration to patients unable to swallow a tablet or capsule. The results of studies comparing the clinical efficacy of different PPI dosage forms and routes of administration, safety considerations, and cost-effectiveness analyses are among the factors to consider when making formulary decisions for this class of drugs.

CONCLUSIONS

While the introduction of new PPI products has expanded the therapeutic options for acid suppression in acutely ill patients, a number of unresolved questions remain surrounding the interchangeability of these products, the clinical significance of one PPI formulation over the other, and how oral/enteral therapy should be used as step-down therapy after parenteral therapy.

Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis

BACKGROUND & AIMS

The optimal management of bleeding peptic ulcer with adherent clot is controversial and may include endoscopic therapy or medical therapy.

METHODS

We searched MEDLINE, BIOSIS, EMBASE, and the Cochrane Library to identify all randomized controlled trials comparing the 2 interventions. Outcomes evaluated in the meta-analysis were recurrent bleeding, need for surgical intervention, length of hospitalization, transfusion requirement, and mortality.

RESULTS

Six studies were identified that included 240 patients from the United States, Hong Kong, South Korea, and Spain. Patients in the endoscopic therapy group underwent endoscopic clot removal and treatment of the underlying lesion with thermal energy, electrocoagulation, and/or injection of sclerosants. Rebleeding occurred in 5 of 61 (8.2%) patients in the endoscopic therapy group, compared with 21 of 85 (24.7%) in the medical therapy group (P = .01), for a pooled relative risk of 0.35 (95% confidence interval, 0.14-0.83; number needed to treat, 6.3). There was no difference between endoscopic therapy and medical therapy in length of hospital stay (mean, 6.8 vs 5.6 days; P = .27), transfusion requirement (mean, 3.0 vs 2.8 units of packed red blood cells; P = .75), or mortality (9.8% vs 7%; P = .54). Patients in the endoscopic therapy group were less likely to undergo surgery (pooled relative risk, 0.43; 95% confidence interval, 0.19-0.98; number needed to treat, 13.3); however, this outcome became nonsignificant when only peer-reviewed studies were considered.

CONCLUSIONS

Endoscopic therapy is superior to medical therapy for preventing recurrent hemorrhage in patients with bleeding peptic ulcers and adherent clots. The interventions are comparable with respect to the need for surgical intervention, length of hospital stay, transfusion requirement, and mortality.

Systematic review and meta-analysis: proton-pump inhibitor treatment for ulcer bleeding reduces transfusion requirements and hospital stay--results from the Cochrane Collaboration

BACKGROUND

Proton-pump inhibitors reduce re-bleeding and surgical intervention, but not mortality, after ulcer bleeding.

AIM

To examine the effects of proton-pump inhibitor treatment on transfusion requirements and length of hospital stay in patients with ulcer bleeding.

METHODS

For the Cochrane Collaboration meta-analysis of randomized-controlled trials of proton-pump inhibitor therapy for ulcer bleeding, outcomes of transfusion requirements and hospital stay were summarized, respectively, as mean (+/-s.d.) units transfused and hospital days. We calculated weighted mean difference with 95% confidence interval. We also performed subgroup analyses according to geographical origin of the randomized-controlled trials.

RESULTS

There was significant heterogeneity among randomized-controlled trials for either outcome. Overall, proton-pump inhibitor treatment marginally reduced transfusion requirements (WMD = -0.6 units; 95% CI: -1.1 to 0; P = 0.05) and length of hospitalization (WMD = -1.1 days; 95% CI: -1.5 to -0.7; P < 0.0001). Most of the randomized-controlled trials did not state precise criteria for administering blood transfusion and discharging patients, thereby limiting the strength of conclusions on the pooled effects.

CONCLUSIONS

Proton-pump inhibitor treatment for ulcer bleeding produces small, but potentially important, reductions in transfusion requirements and length of hospitalization.

Use of acid-suppression therapy for treatment of non-variceal upper gastrointestinal bleeding

PURPOSE

Prognostic factors in patients with peptic ulcer bleeding and therapeutic strategies for preventing the recurrence of bleeding are described.

SUMMARY

The risk of complications and death in a patient with acute upper gastrointestinal bleeding can be predicted based on certain clinical factors, the most important being the endoscopic findings. Proton pump inhibitors (PPIs) are the drugs of choice for patients with peptic ulcer bleeding because the drugs are more effective than histamine H2-receptor antagonists for maintaining the target intragastric pH (6 or higher) and preventing the recurrence of peptic ulcer bleeding, although an impact on mortality has not been demonstrated. High-dose intravenous PPI therapy should be used for patients at high risk of rebleeding (based on endoscopic findings). Oral PPI therapy may be used for low-risk patients. Underlying causes of ulcers should also be addressed and treated as necessary.

CONCLUSION

Acid-suppression therapy using PPIs is effective for reducing the risk for recurrence of peptic ulcer bleeding.

The efficacy of high- and low-dose intravenous omeprazole in preventing rebleeding for patients with bleeding peptic ulcers and comorbid illnesses

This study sought to determine if high-dose omeprazole infusion could improve the control of rebleeding in patients with comorbid illnesses and bleeding peptic ulcers. After achieving hemostasis by endoscopy, 105 patients were randomized into high-dose (n = 52) and low-dose (n = 53) groups, receiving 200 and 80 mg/day omeprazole, respectively, as a continuous infusion for 3 days. Thereafter, oral omeprazole, 20 mg/day, was given. The cumulative rebleeding rates comparatively rose in both groups (high-dose vs. low-dose group), beginning on day 3 (15.4% vs. 11.3%), day 7 (19.6% vs. 20%), and day 14 (32.7% vs. 28.9%), until day 28 (35.4% vs. 33.3%), and were not significantly different between the two groups (P > 0.50). Multiple logistic regression confirmed that a serum albumin level <3 g/dL was an independent factor associated with rebleeding (P = 0.002). For patients with comorbidities, 3-day omeprazole infusion, despite increasing the daily dose from 80 to 200 mg, was not adequate to control peptic ulcer rebleeding.

Appropriate use of intravenous proton pump inhibitors in the management of bleeding peptic ulcer

Rebleeding from peptic ulcers is a major unsolved problem in the management of acute upper gastrointestinal bleeding. Our goal was to review what is known and what remains to be learned about the effectiveness of antisecretory therapy for acute upper gastrointestinal bleeding. We reviewed the data regarding the effectiveness of endoscopic therapy, the prediction of those at increased risk for rebleeding, and the effectiveness of antisecretory drug therapy in preventing rebleeding with or without endoscopic hemostasis. Proton pump inhibitor therapy without endoscopic hemostasis is ineffective clinically for stopping bleeding or preventing rebleeding. Endoscopic hemostasis remains the cornerstone of therapy. The data are consistent with the notion that reliable maintenance of the intragastric pH at > or = 6 after endoscopic hemostasis is associated with the lowest rebleeding rates. H2-receptor antagonists are ineffective for achieving this goal. Intermittent bolus and oral administration of proton pump inhibitors are equivalent and fail to achieve this goal, which can only be accomplished by bolus administration of a proton pump inhibitor (e.g., 80 mg) followed by a constant infusion (e.g., 8 mg/hr). Whether the combination of endoscopic hemostasis and pH control is equal or superior to selected second-look endoscopy is unknown. A treatment algorithm is suggested.

Prevention of the rehaemorrhage of bleeding peptic ulcers: effects of Helicobacter pylori eradication and acid suppression

AIM

This study aimed to investigate the consequences of Helicobacter pylori eradication and acid suppression on rehaemorrhage caused by bleeding peptic ulcers.

METHODS

A total of 320 patients who had been diagnosed with bleeding peptic ulcers between January 1994 and December 2001 were included in the study. Cases between 1994 and 1997, prior to the introduction of eradication therapy, were assigned to group A, whereas those between 1998 and 2001, after the eradication therapy, were assigned to group B.

RESULTS

Of the 320 cases, 162 were designated as group A (113 gastric ulcers and 49 duodenal ulcers) and 158 as group B (116 and 42, respectively). Rehaemorrhage occurred in 24 cases (15%) and five cases (3%) in groups A and B, respectively, presenting a significantly decreased rate of rehaemorrhage in group B. Among those without eradication, rehaemorrhage was observed in 15 of 128 cases (12%) that received treatment with histamine(2)-receptor antagonist (famotidine), and 14 of 142 cases (10%) treated with proton-pump inhibitors, with no significant difference between the two.

CONCLUSIONS

Helicobacter pylori eradication lowered the rates of rehaemorrhage. Treatment with histamine(2)-receptor antagonist or proton-pump inhibitors did not produce a difference in the rate of rehaemorrhage.

Treatment of nonvariceal upper gastrointestinal bleeding

PURPOSE

The etiology, pathophysiology, prognostic factors, pharmacologic treatment, and pharmacoeconomic considerations of nonvariceal upper-gastrointestinal-tract bleeding (UGB) are reviewed.

SUMMARY

UGB is associated with substantial morbidity and mortality. While UGB can be caused by a wide variety of medical conditions, 50% of UGB cases are caused by peptic ulcers. Approximately 80% of all UGB episodes stop bleeding spontaneously. Recurrence of gastrointestinal hemorrhage is associated with an increased mortality rate, a greater need for surgery, blood transfusions, a prolonged length of hospital stay, and increased overall health care costs. All patients with UGB should be evaluated for signs and symptoms of hemodynamic instability and active hemorrhage. Endoscopy within the first 24 hours of a UGB episode is considered the standard of therapy for the management of the initial hemorrhage. However, approximately 20% of patients will experience a rebleeding episode. Acid-suppressive therapy with proton-pump inhibitors (PPIs) in addition to endoscopic hemostasis is effective in reducing the frequency of rebleeding, the need for surgery, transfusion requirements, and the length of hospital stay, but not mortality rates. There are multiple dosing options for administration of PPIs in this setting. More studies are necessary to elucidate the best therapeutic approach to manage UGB.

CONCLUSION

Acid-suppressive therapy is beneficial in the management of UGB. It reduces the frequency of rebleeding, the need for surgery, transfusion requirements, and the length of hospital stay. To date, no pharmacologic intervention has demonstrated a reduction in the mortality rates of patients with UGB. An optimal acid-suppressive regimen has not yet been clearly established.