To the Editor We read with great interest the article by Sachar et al.1 The authors are to be commended for their thorough literature review and careful analysis. However, several issues may need clarification before jumping to conclusions.
First, how endoscopic therapy might interact with pharmacotherapy to determine outcomes was not addressed. Given that monotherapy with epinephrine injection is suboptimal to achieve hemostasis, it is intriguing to clarify whether the dosage of a proton pump inhibitor (PPI) should differ according to endoscopic treatment, especially when the meta-analysis included 6 studies that allowed injection therapy alone. Another important determinant for recurrent bleeding is the ulcer stigmata because an actively spurting ulcer is much more likely to rebleed. This kind of lesion may require more potent inhibition of gastric acid. In fact, an earlier randomized trial has demonstrated that in patients with active arterial bleeding ulcers, an intermittent PPI dose (intravenous, 40 mg every 8 hours) could not effectively decrease rebleeding compared with histamine receptor antagonist (ranitidine).2 Conceivably, a higher dose of PPI may be indicated in patients at higher risk of rebleeding. A recent randomized trial has actually showed that double dose of oral PPI outperformed the standard dose among the high-risk patients (Rockall scores ≧6) after 3-day PPI infusion.3
Hsu Y, Lin H. Intermittent Bolus or Continuous Infusion of Proton Pump Inhibitors for Ulcer Bleeding?. JAMA Intern Med. 2015;175(3):461. doi:10.1001/jamainternmed.2014.7797