High-Dose PPI Therapy for High-Risk Patients with GI Bleeding

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)

In patients with a Rockall score ≥6, doubling the oral proton pump-inhibitor dose lowered risk for 28-day rebleeding.

The Rockall scoring system identifies the risk of rebleeding from peptic ulcers. Standard therapy for patients with high-risk endoscopic stigmata is endoscopic therapy plus high-dose, intravenous proton pump-inhibitor (PPI) treatment for 3 days, followed by an oral PPI. Patients with a Rockall score ≥6 have an elevated risk for rebleeding after the 3 days of intravenous therapy. Now, investigators in Taiwan have evaluated the impact of higher oral PPI doses on 28-day rebleeding risk in high-risk patients.

A total of 293 patients with high-risk endoscopic stigmata were treated endoscopically and then received 3 days of high-dose PPI therapy. One hundred and eighty-seven patients with a Rockall score ≥6 without subsequent bleeding on day 3 were then randomized to receive 40 mg of oral esomeprazole once or twice daily for 11 days, then once daily until day 28. Patients with a score <6 received once-daily esomeprazole.

Patients with a Rockall score ≥6 who received twice-daily PPI therapy had a 28-day rebleeding rate of 10.8% compared with 28.7% in the standard dose group (relative risk, 0.37; 95% confidence interval, 0.19–0.73). Patients with a Rockall score <6 had rebleeding rates similar to those in patients with high scores receiving twice-daily PPI therapy. The authors conclude that the Rockall score is a good predictor of rebleeding and that double-dose oral PPI treatment after intravenous therapy can reduce rebleeding in high-risk patients.

Citation(s):

Cheng HC et al. Double oral esomeprazole after a 3-day intravenous esomeprazole infusion reduces recurrent peptic ulcer bleeding in high-risk patients: A randomised controlled study. Gut 2014 Mar 21; [e-pub ahead of print].