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Editor's Correspondence
October 11, 2010

High-Dose PPIs in Patients With Variceal Hemorrhage

Author Affiliations

Author Affiliations: Department of Pharmacy, University of Michigan Hospitals and Health Centers, and College of Pharmacy, Ann Arbor (Drs Alaniz and Welage); and Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Mohammad).

Arch Intern Med. 2010;170(18):1698. doi:10.1001/archinternmed.2010.358

The meta-analysis by Wang et al1 shows no additional benefit in reducing the rates of rebleeding, surgical intervention, or mortality with the use of high-dose PPIs compared with non–high-dose PPIs for the treatment of patients with bleeding peptic ulcers. We would like to comment on another clinical condition in which we have seen increased use of high-dose PPIs: acute variceal hemorrhage. To our knowledge, there are no prospective studies that have evaluated use of high-dose PPIs in this setting. We previously conducted a retrospective cohort study to assess the effect of high-dose PPIs (defined as >24 hours continuous infusion of pantoprazole) on patient outcomes.2 We compared patients using high-dose PPIs with patients using non–high-dose PPIs (defined as ≤24 hours of infusion of pantoprazole or intermittent acid suppression). Both groups received standard octreotide therapy for the treatment of variceal hemorrhage. Both groups were similar at baseline with respect to Child-Pugh score, international normalized ratios, Acute Physiology and Chronic Health Evaluation (APACHE) III score, and hemoglobin concentration. The mean (SD) duration of high-dose PPI was 63.3 (48.9) hours (range, 25-332 hours). Results showed no difference in outcome with respect to transfusion of packed red blood cells or platelets. Curiously, the high-dose PPI group received more units of fresh-frozen plasma throughout the hospital stay compared with the non–high-dose PPI group (mean [SD], 6.1 [10.6] U vs 2.9 [6.2] U; P = .05). Furthermore, there was an increased rate of rebleeding in the high-dose PPI group, although this was nonsignificant (13% vs 5%; P = .12). Although differences observed may theoretically be attributed to differences in the 2 groups owing to the retrospective nature of the study, it is interesting that Wang et al1 also observed an increased rate of rebleeding in the high-dose PPI group compared with the non–high-dose group (12.3% vs 10.2%; odds ratio, 1.3 [95% confidence interval, 0.88-1.91]). Overall, the results of our study extend the findings of Wang et al and suggest that use of high-dose PPI therapy does not confer additional benefit in the management of variceal hemorrhage.

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