Acid suppression and upper GI bleeding

Abstract

S IRS, We read the review article written by Barkun and colleagues with great interest.1 Based on our own study of this subject, we would like to add some critical points. The authors quote the 24-h pH-metry study of Ballesteros et al. stating that infusion of H2-receptor antagonists (H2-RAs) is superior to bolus injection.2 We would like to emphasize that this is only true for the first 24 h of treatment. Thereafter, as shown in our study, there is no significant difference left between ranitidine infusion and bolus injections.3 Our findings emphasize that one has to be cautious about generalizing study results beyond the observed study period. The authors quote that the tolerance of H2-RAs occurs within 72 h of oral therapy. In our study, highly significant tolerance had already occurred on the second day of intravenous ranitidine treatment, rendering it inappropriate for situations in which high intragastric pH levels appear to be essential.3 Concerning the question of whether a dose of 4 or 8 mg/h of omeprazole should be used for continuous infusion, Barkun et al. mention two studies with contrasting results. There is now a third study, published by Hasselgren et al.,4 which demonstrates the superiority of the omeprazole 8 mg/h infusion. We feel that a discussion about omeprazole bolus injection and continuous infusion treatment is missing. In our study, we demonstrated the superiority of continuous omeprazole infusion (8 mg/h after a loading dose of 80 mg) over omeprazole injection (40 mg/6 h after a loading dose of 80 mg) therapy.3 However, after the first day of therapy, only the percentage of time with pH > 4 (97% vs. 99%) differed significantly between omeprazole injection and infusion, whereas the median pH and percentage of time with pH gt; 6 did not. We therefore often change from omeprazole infusion therapy to bolus injection when patients change to the regular ward after 24 h on the intensive care unit.