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.
LaineL., PetersonW.L.Bleeding peptic ulcer. N Engl J Med.1994; 331: 717–725.
2.
LongstrethG.F.Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol.1995; 90: 206–210.
3.
MarshallJ.K., CollinsS.M., GafniA.Prediction of resource utilization and case cost for acute nonvariceal upper gastrointestinal hemorrhage at a Canadian community hospital. Am J Gastroenterol.1999; 94: 1841–1846.
4.
LoewenP.S., ZedP.J., UllattikulamJ., JewessonP.An evaluation of acute upper gastrointestinal bleeding management. Results on file.2002; Vancouver, BC, Canada.
5.
ForrestJ.A., FinlaysonN.D., ShearmanD.J.Endoscopy in gastrointestinal bleeding. Lancet.1974; 2: 394–397.
HsuP.I., LaiK.H., LinX.Z.. When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of rebleeding. Gastrointest Endosc.1996; 44: 382–387.
8.
LauJ.Y., SungJ.J., LeeK.K.. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med.2000; 343: 310–316.
9.
CookD.J., GuyattG.H., SalenaB.J., LaineL.A.Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology.1992; 102: 139–148.
10.
GreenF.W.Jr, KaplanM.M., CurtisL.E., LevineP.H.Effect of acid and pepsin on blood coagulation and platelet aggregation. A possible contributor to prolonged gastroduodenal mucosal hemorrhage. Gastroenterology.1978; 74: 38–43.
11.
ZedP.J., LoewenP.S., SlavikR.S., MarraC.A.Meta-analysis of proton pump inhibitors in treatment of bleeding peptic ulcers. Ann Pharmacother.2001; 35: 1528–1534.
12.
BrunnerG., ChangJ.Intravenous therapy with high doses of ranitidine and omeprazole in critically-ill patients with bleeding peptic ulceration of the upper intestinal tract: an open randomized controlled trial. Digestion.1990; 45: 217–225.
LanasA., ArtalA., BlasJ.M., ArroyoM.T., Lopez-ZaborrasJ., SainzR.Effect of parenteral omeprazole and ranitidine on gastric pH and the outcome of bleeding peptic ulcer. J Clin Gastroenterol.1995; 21: 103–106.
15.
VillanuevaC., BalanzoJ., TorrasX.. Omeprazole versus ranitidine as adjunctive therapy to endoscopic injection in acutely bleeding ulcers: a prospective and randomized study. Endoscopy.1995; 27: 308–312.
Schaffalitzky de MuckadellO.B., HavelundT., HarlingH.. Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers. Scand J Gastroenterol.1997; 32: 320–327.
18.
HasselgrenG., LindT., LundellL.. Continuous intravenous infusion of omeprazole in elderly patients with peptic ulcer bleeding. Scan J Gastroenterol.1997; 32: 328–333.
19.
LinH.J., LoW.C., LeeF.Y., PerngC.L., TsengG.Y.A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy. Arch Intern Med.1998; 158: 54–58.
20.
LeontiadisG.I., SharmaV.K., HowdenC.W.Systematic review and meta-analysis of proton pump inhibitor therapy in peptic ulcer bleeding. BMJ.2005; 330(7491): 568.
21.
EnnsR.A., GagnonY.M., RiouxK.P., LevyA.R.Cost-effectiveness in Canada of intravenous proton pump inhibitors for all patients presenting with acute upper gastrointestinal bleeding. Aliment Pharmacol Ther.2003; 17: 225–233.
22.
BarkunA.N., HerbaK., AdamV., KennedyW., FalloneC.A., BardouM.High-dose intravenous proton pump inhibition following endoscopic therapy in the acute management of patients with bleeding peptic ulcers in the USA and Canada: a cost-effectiveness analysis. Aliment Pharmacol Ther.2004; 19(5): 591–600.
23.
BarkunA., BardouM., MarshallJ.K.Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med.2003; 139: 843–857.
24.
International classification of diseases, 9th revision, clinical modification.Washington, DC: Public Health Service; 1980.
25.
BarkunA., FalloneC.A., ChibaN.. A Canadian clinical practice algorithm for the management of patients with nonvariceal upper gastrointestinal bleeding. Can J Gastroenterol.2004; 18: 605–609.
26.
ZuccaroG.Jr. Bleeding peptic ulcer: pathogenesis and endoscopic therapy. Gastroenterol Clin North Am.1993; 22: 737–750.
27.
BrunnerG., LunaP., HartmannM., WurstW.Optimizing the intragastric pH as a supportive therapy in upper GI bleeding. Yale J Biol Med.1996; 69: 225–231.
