The likelihood and prevalence of GI bleeds increase with advances with age and can be attributed as a significant cause of morbidity and mortality if not appropriately treated.  The location of the bleed dictates treatment and physical examination and laboratory data are essential for aiding in the diagnosis but also dictating management.

Risk stratification is useful and is evaluated with endoscopy, clinical and laboratory techniques.  Providers must formulate a plan to triage, determine the source of the bleed and treat a GI bleed but also must assess the risk of rebleeding.  Factors associated with re-bleeding can be identified and include hemodynamic instability, hemoglobin < 10 g/L, active bleeding at the time of endoscopy, large ulcer size and ulcer location.  

The patient in question is a high-risk patient with a bleeding ulcer on endoscopy.  My preceptor was inquiring whether the use of PPIs via continuous IV or intermittently done through boluses was the best approach for this patient and had significant conversations as to the appropriate treatment approach with the broader team.

The article, indexed for Medline, is a systematic review and meta analysis that comes from JAMA Internal Medicine and discusses whether intermittent or continuous PPI therapy should be used to treat high-risk bleeding ulcers.  The authors reviewed ~2115 records and ultimately included 13 studies in their meta analysis, which directly answered the question – intermittent PPI therapy is comparable to the current guideline-recommended regimen of intravenous bolus plus a continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers.  The data sets provided in the article highlight the fact that the intermittent bolus’ are favored in practice and the risk ratios support that data with 95% confidence interval.

The article also addresses the costs associated with both forms of treatment and notes that intermittent PPI therapy should be used as the treatment of choice because its lower cost and more easily available.  The authors make the recommendation for the revision of the current standard of care and amend the guidelines to state that intermittent PPI therapy should be incorporated in practice and used as the preferred treatment method moving forward.

There were not many articles that particularly addressed this question because the standard of care is written.  However, after discussing this article with the broader team, the patient in question was treated with intermittent boluses of PPI, especially based on the data this article concluded.  It also prompted the question on the team of the efficacy of PO vs. IV PPI use and stemmed a PICO search for me but also allowed me to contribute during rounds.

Download the article: Intermittent v Continuous PPI Therapy

https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults#H11

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