Optimize PPI Dosing for Nonvariceal Upper GI Bleeds

You'll get questions about using proton pump inhibitors (PPIs) for NONvariceal upper GI bleeding...due to updated guidelines.

Continue to generally start a PPI before endoscopy for a suspected upper GI bleed. This won't decrease rebleeding risk...but it may lead to fewer interventions during endoscopy.

Guidelines continue to advise using a PPI infusion. But consider using 40 mg IV every 12 hours instead. Mounting evidence suggests intermittent doses seem to work as well as an 8 mg/hr drip.

Lean toward giving a PPI loading dose, such as pantoprazole 80 mg, before a drip or BID dosing. Raising the pH faster may help with clotting...but there aren't data to say if this improves outcomes.

Expect patients to typically undergo endoscopy within 24 hours. Check the endoscopy report to help guide your postprocedure PPI plan.

Change to a once-daily PPI for patients who DIDN'T need an intervention during endoscopy...such as hemoclips or a heater probe.

Continue twice-daily dosing for at least 3 days in those who DID receive an intervention...to reduce risk of rebleeding or surgery. Consider continuing for up to 14 days...this may further reduce risk.

Transition IV PPI therapy to oral once a patient is hemodynamically stable and tolerating oral intake.

At discharge, ensure patients on twice-daily dosing have instructions to switch to once daily by 14 days. Also verify the total PPI duration is indicated...such as 8 weeks for a peptic ulcer.

See our chart, Managing Upper GI Bleeds, for tips on tapering PPIs, treating patients also taking antithrombotics, and more.

And get our chart, Esophageal Variceal Bleeding FAQs, for guidance when endoscopy reveals a source of variceal bleeding.

Key References

  • Ann Intern Med 2019;171(11):805-22
  • BMJ 2019;364:l536
  • Am J Health Syst Pharm 2017;74(3):109-16
  • JAMA Intern Med 2014;174(11):1755-62
Hospital Pharmacist's Letter. January 2020, No. 360121



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