Critical Care, GI, Improving Outcomes, Mythbusting

PPIs, ACG, and GI bleeders.

The PPI wheel is reinvented.

There is so much evidence to contradict the PPI drip, that it drives me mad that some still request a drip. We have yet another study comparing PPI bolus vs infusion for the prevention of bleeding after endoscopic submucosal dissection. Not surprisingly, as we have seen in the actively bleeding GI patient before, there was no difference in delayed bleeding or high risk ulcer stigmata with PPI bolus or drips in this study that evaluted 273 randomized patients.

Yet we continue to get push back about PPI drips. Despite this meta-analysis showing high-dose infusion for variceal hemorrhage is not beneficial, or this JAMA Internal Medicine meta-analysis  showing similar outcomes for bolus treatment vs bolus +infusion in terms of rebleeding within 3, 7, and 30 days, the need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay.  Perhaps this recent meta-analysis of 12 articles demonstrating that cirrhotic patients who use PPIs are at a higher risk of developing spontaneous bacterial peritonitis may help (OR = 2.17). While the meta-analysis looked at taking PPIs on a daily basis and future risk of developing SBP, perhaps it is not a huge stretch to suggest that an acutely ill cirrhotic GI bleeder on 8 mg per hour of your favorite PPI may be more prone to develop SBP.

 

So, what does the American College of Gastroenterology say?

Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg/h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death (Conditional recommendation)… After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot (Strong recommendation)…. A meta-analysis of 8 trials showed that, compared to endoscopic therapy alone (sclerotherapy or EVL), endoscopic plus pharmacological (octreotide, somatostatin, vapreotide) therapy improved the initial control of bleeding and 5-day hemostasis without differences in mortality or severe adverse events… EGD, performed within 12 hours, should be used to make the diagnosis and to treat variceal hemorrhage, either with EVL or sclerotherapy (Class I, Level A).

So, even ACG acknowledges that PPIs (and octreotide, while we’re at it) did not improve outcomes, yet they advocate for their use.  Important to note, they do advocate for urgent endoscopy – which they define as within 12 hours.  Next time you have to discuss a PPI drip, you can say that ACG acknowledges that it does not improve outcomes, and that high dose PPIs may predispose your sick patient to SBP.

http://gi.org/guideline/prevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis/

http://gi.org/guideline/management-of-patients-with-ulcer-bleeding/

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