Thirty-day rebleeding rates were similar with use of oral and IV PPIs after successful endoscopic therapy, but further studies are needed.
High-dose intravenous proton-pump inhibitor (PPI) treatment can reduce rebleeding after endoscopic therapy in patients with high-risk lesions. Some studies suggest that oral PPI treatment may have a similar effect.
Investigators in Hong Kong compared 30-day rebleeding rates in patients randomized to receive intravenous (IV) versus oral high-dose PPI treatment after successful endoscopic therapy for bleeding peptic ulcers. One group of 118 patients received 80 mg of esomeprazole, followed by 8 mg/h intravenously and oral placebo capsules every 12 hours for 72 hours. Another group of 126 patients received 40 mg of oral esomeprazole every 12 hours and an intravenous placebo bolus and drip for 72 hours.
Rebleeding rates were similar in the IV-PPI and oral-PPI groups at 72 hours (5.1% and 2.4%), 7 days (6.8% and 5.6%), and 30 days (7.7% and 6.4%). Also similar between groups were rates of unscheduled endoscopic therapy, angiography, surgery, hospital stay, and blood transfusion. The study was originally planned for 203 patients in each group but was stopped prematurely because of difficulty in recruiting patients. The authors conclude that oral esomeprazole may be considered as an alternative when IV therapy cannot be given. They emphasize that the study was not powered to demonstrate that the two approaches are equivalent.
No trend toward superiority of IV therapy to oral therapy was observed that would suggest that recruitment of the additional patients would have changed the results. The authors are correct in suggesting that an equivalency or noninferiority trial would be stronger, but such studies require a very large number of patients and are unlikely to be forthcoming. Studies similar to this one in other populations are needed. Should those studies provide similar results, the potential substitution of oral for IV PPIs could reduce the cost of care.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) reviewing Sung JJY et al. Am J Gastroenterol 2014 Apr 29.
Sung JJY et al. Effects of intravenous and oral esomeprazole in the prevention of recurrent bleeding from peptic ulcers after endoscopic therapy. Am J Gastroenterol 2014 Apr 29; [e-pub ahead of print].