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No benefit of higher dose PPIs for prevention of rebleeding of peptic ulcers

Clinical Question:
Following endoscopic treatment for bleeding peptic ulcers, do high-dose proton pump inhibitors reduce the rate of rebleeding more than non-high-dose proton pump inhibitors?

Bottom Line:
For patients with bleeding peptic ulcers that are treated endoscopically, high-dose proton pump inhibitors (PPIs) do not decrease the rate of rebleeding, affect mortality, or reduce the need for further surgical intervention more than non-high-dose PPIs.. (LOE = 1a)

Reference:
Wang CH, Ma MH, Chou HC, et al. High-dose vs non-high-dose proton pump inhibitors after endoscopic treatment in patients with bleeding peptic ulcer: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2010;170(9):751-758.  [PMID:20458081]

Study Design:
Meta-analysis (randomized controlled trials)

Funding:
Unknown/not stated

Setting:
Various (meta-analysis)

Synopsis:
These authors searched databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, and reviewed bibliographies from retrieved articles, to identify randomized controlled trials that compared the use of high-dose versus non-high-dose PPIs for the prevention of rebleeding in endoscopically treated bleeding peptic ulcers. High-dose PPIs were defined as an 80-mg bolus of omeprazole or pantoprazole, followed by 8 mg per hour or higher of intravenous infusion for 72 hours. Non-high-dose PPI doses varied across studies. Of the 2 largest studies, 1 used intravenous omeprazole or pantoprazole 40 mg daily for 3 days and the other used oral omeprazole 40 mg twice daily for 3 days. Two authors independently assessed study eligibility, data extraction, and quality assessment; discrepancies were resolved by consensus. Quality criteria for the eligible studies were assessed using the 5-point Jadad scale and only those studies scoring 3 points or higher were included. Combining data from the 7 included trials (N = 1157) suggests that using high-dose PPIs as compared with non-high-dose PPIs does not significantly reduce the rate of rebleeding after endoscopic therapy at 30 days postrandomization. Furthermore, the use of high-dose PPIs does not decrease mortality or the need for surgical intervention. Although there was no statistical heterogeneity detected, the studies were clinically heterogeneous in study design, patient inclusion criteria, and route and amount of non-high-dose PPIs administered. No formal analysis for publication bias was performed.

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