The role of intravenous proton pump inhibitors in the modern management of nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal (GI) bleeding is a common cause of hospitalization and despite effective endoscopic treatments, it is responsible for a significant societal burden due to the associated morbidity, mortality and financial implications. As it has long been hypothesized that acid suppression may help to improve outcomes of patients with gastroduodenal ulcer bleeding, acid-suppressing agents such as histamine-2 receptor antagonists (H 2 RAS) and intravenous (i.v.) proton pump inhibitors (PPIs) have been the subject of study. However, results for H2RAs show little if any improvement in outcomes, which may be explained by their insufficient acid suppression and the existence of rapid drug tolerance. The advent of i.v. proton pump inhibition has made possible a more profound and sustained, predictable acid suppression without the development of tolerance to the drug. Recently published studies on the use of i.v. PPIs in over 1,500 patients have shown that they have an excellent safety profile. Cost-effectiveness decision models have also suggested, in a preliminary fashion, their cost-effectiveness for use following endoscopic hemostasis in patients with bleeding ulcers. The Canadian Registry of Patients with Upper Gastrointestinal Bleeding Undergoing Endoscopy (RUGBE) recorded information on patient characteristics, diagnosis and treatment from 1999-2002 and preliminary data indicate protective effects of endoscopic treatment and PPI use in specific patient subgroups. Randomized trials and meta-analyses have shown that acute high-dose i.v. PPI administration leads to improvements in patients undergoing endoscopic hemostasis for bleeding gastroduodenal ulcers and who also show high risk for rebleeding. However, the optimum dose, timing of administration and subgroups of patients who will benefit most from such treatment need to be further characterized. (C) 2003 Prous Science. All rights reserved.