Overuse of Intravenous Proton-Pump Inhibitors in the Treatment of Low-Risk Upper Gastrointestinal Bleeding

In patients with acute upper GI bleeding (UGIB), current best practice is to discontinue or transition (to oral) intravenous proton pump inhibitors (PPIs) when esophagogastroduodenoscopy (EGD) reveals low risk or no peptic ulcer disease (PUD).

This retrospective study from a large academic medical center evaluated the use of intravenous PPIs in patients admitted with acute UGIB due to low-risk PUD or non-PUD UGIB. Complete clinical data including endoscopic lesions and the duration of intravenous PPI therapy were recorded.

Of 335 patients with acute UGIB, 253 had no PUD or an ulcer with only low-risk stigmata; 79 patients [31% (95% CI: 26%-37%)] received the appropriate duration of IV PPI. For patients with low-risk PUD (n=42), patients received on average 5.3 excess doses of intravenous PPI, and patients receiving continuous intravenous PPI received an average of 41 additional hours of IV PPI. Likewise, excess PPI therapy was common for patients found to have no lesions or no PUD. Lesions most often associated with inappropriate IV PPI use included: no identifiable lesion (n=59; 34%), low-risk PUD (n=42; 24%), gastritis (n=31; 18%), esophagitis (n=24, 14%), and AVMs (n=21, 12%). The length of hospital stay was shorter in patients who received appropriate PPI therapy after EGD compared with those who did not (4.3 vs. 7.2 d, P =0.001).

IV PPIs are grossly overused in patients with UGIB, suggesting that there is substantial room for improvement in the use of PPIs in patients with acute UGIB.