Skipping the Drip: Intravenous Proton Pump Inhibitor Bolus Therapy Leads to Poor Outcomes in High-Risk Bleeding

Background and Aim The aim of this study was to evaluate the impact of a change in our institute's protocol from continuous intravenous (IV) proton pump inhibitor (PPI) therapy to bolus IV PPI therapy for the treatment of peptic ulcer-related bleeding on patient outcomes. Current guidelines recommend PPI therapy through high-dose IV bolus followed by continuous infusion for bleeding ulcers. Conflicting data have been reported regarding the practice shift to intermittent IV PPI therapy. Methods A retrospective record review was conducted of patients treated at West Virginia University between 2017 and 2018 for peptic ulcer related bleeding who underwent endoscopy and had high-risk stigmata. Relevant variables were identified. Outcomes were compared between groups based on PPI strategy. The primary endpoint was any poor outcome defined as rebleeding, need for embolization or surgery, or mortality during hospital stay. Results A total of 130 patients were included, with a mean age of 62.18 years. Continuous PPI infusion was used in 39.23%, whereas bolus IV PPI was used 60.76%. Poor outcome was encountered in 11 (21.57%) patients in the continuous and 33 (41.77%) patients in the bolus group (p = 0.028). On multivariable analyses, bolus PPI strategy was independently linked to poor outcome (Wald's odds ratio: 2.8; 95% CI: 1.21-6.84; p = 0.019) and an increased need for embolization/surgery (OR: 4.12, 95% CI: 1.14-19.99; p = 0.046). Conclusions IV bolus therapy showed worse outcomes compared with continuous IV PPI therapy for patients with peptic ulcer bleeding with high-risk features. More robust data are needed before a practice shift to bolus PPI may be appropriate.