Sunday, 13 January 2013

Drinking the PPI Hate-O-Rade

Hi all, sorry about the extended hiatus.  I was away after Christmas for about 12 days and have been getting back in the swing of things over the past week.  

Since the break, one great new blog that has popped up on the FOAMed landscape is the boringem blog, started by Brent Thoma, one of the other ER residents in Saskatoon.  You can check it out here.

Also, look for a new blog section for med ed. videos in the near future.  I'll start it out with a cardiology parody I made back as a med student.  Watch for a How To video on making a homemade cricothyrotomy trainer soon.

Onto the blog.

Proton pump inhibitors (PPIs) have been taking a beating in the FOAM arena lately, with a large portion of the credit going to David Newman of SmartEM and theNNT.  Just before Christmas, theSGEM blog did an excellent blog post and podcast on this topic as well.  The links above will allow you to review the common misconceptions surrounding PPIs, as well as the evidence to support this. 

Briefly, PPIs have been thought of as a panacea over the past decade, with the 80 and 8 bolus + infusion protocol thought of as the cure for all UGIBs.  Unfortunately, this 2010 Cochrane systematic review on PPIs for UGIB showed no reduction in mortality at 30 days, nor did it show any reduction in rebleed rates or requirement for surgery at 30 days.  Transfusion requirements and hospital LOS could not be analyzed, but there is no good, reproducible evidence that these outcomes are improved either. 

At this point, it seems pretty obvious that I'm not too keen on the empiric use of PPIs for UGIB.  Unfortunately, there's one reason we will not win this battle with gastroenterologists any time soon.  Need for endoscopic intervention.  This RCT by Lau et al. showed that despite no reduction in other significant outcomes, there was a decreased need for endoscopic therapy (28% vs. 19%, p <0.007).

As ER physicians, we do not admit or scope our UGIB patients.  We resuscitate, stabilize and refer for endoscopy.  Despite the fact that there is no change in major outcomes (eg. mortality, rebleeding and surgery), a faster endoscopy requiring less intervention remains a significant outcome for the physician performing it.  For that reason, I find it difficult to believe this battle will be won by ER physicians any time in the near future.  I would love to be proven wrong.

My question to readers is if you have discussed this with your GI docs, and what reasoning they are using for the PPI infusions?  Please post in the comments if you have.

However, I think it remains important for med students, residents and nurses to understand that the PPI infusion is not the most critical intervention in the course of the UGIB patient. 

Bottom Line: PPIs do not reduce 30 day mortality, rebleed rates or surgery requirements at 30 days.  However, because of reduced need for endoscopic intervention and the prolonged period required for knowledge translation, their empiric use will continue for the foreseeable future.




Cochrane Database Syst Rev. 2010 Jul 7;7:CD005415. Review. PubMed PMID: 20614440

N Engl J Med. 2007 Apr 19;356(16):1631-40.


  1. I've only ever seen PPI vs placebo studied. Has there ever been an RCT of 80+8 pantoloc versus a more convenient and less labor intensive regimen, say 80 bolus then 40 iv bid or something similar? I mean, how blocked can you proton pumps get? If I'm giving this medication, knowing that the best I can hope for is this questionable outcome of decreased need for endoscopy, at least let me do it without tying up an IV line and making one of my nurses waste his/her time calculating infusion rates etc.

  2. Hey Chris,

    Great question, I wonder the same. I'm still looking for some good evidence to support you for using bolus PPI pre-endoscopy. This systematic review looks at bolus vs. 80+8 in 7 RCTs, and finds no difference in outcomes. However, it is POST-endoscopy. I'll keep looking though.