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Review
. 2017 Aug;83(8):1619-1635.
doi: 10.1111/bcp.13258. Epub 2017 Mar 21.

Comparing intravenous and oral proton pump inhibitor therapy for bleeding peptic ulcers following endoscopic management: a systematic review and meta-analysis

Alberto Tringali  1 , Raffaele Manta  1 , Mariano Sica  1 , Gabrio Bassotti  2 , Riccardo Marmo  3 , Massimiliano Mutignani  1
Affiliations
Review

Comparing intravenous and oral proton pump inhibitor therapy for bleeding peptic ulcers following endoscopic management: a systematic review and meta-analysis

Alberto Tringali et al. Br J Clin Pharmacol. 2017 Aug.

Abstract

Background and aims: The efficacy of proton pump inhibitors (PPIs) has been demonstrated for bleeding peptic ulcers but the route of administration remains controversial. Several studies have demonstrated that high-dose oral PPIs are as effective as intravenous PPIs in reducing recurrent bleeding. However, current guidelines recommend intravenous PPIs after endoscopic treatment. Previous data based on numbers that were too small to enable a firm conclusion to be reached suggested that oral and intravenous PPIs had equivalent efficacy. We undertook a meta-analysis to compare oral and intravenous PPIs in patients with bleeding peptic ulcers after endoscopic management.

Methods: A literature search was undertaken using MEDLINE, EMBASE and the Cochrane Library, between 1990 and February 2016, to identify all randomized controlled trials (RCTs) that assessed the efficacy of PPIs administered by different routes. Nine RCTs, involving 1036 patients, were analysed. Outcomes were: recurrent bleeding, blood transfusion requirement, duration of hospital stay, a need for repeat endoscopy, surgery and 30-day mortality.

Results: There were no differences in the rebleeding rates [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.60, 1.46; P = 0.77], need for surgery (OR 0.77, 95% CI 0.25, 2.40; P = 0.65), need for repeat endoscopy (OR 0.69, 95% CI 0.39, 1.21; P = 0.19), need for blood transfusion [(MD) -0.03, 95% CI -0.26, 0.19; P = 0.76], duration of hospital stay (MD -0.61, 95% CI -1.45, 0.23; P = 0.16) or 30-day mortality (OR 0.89, 95% CI 0.27, 2.43; P = 0.84) according to the route of administration.

Conclusions: Oral PPIs represent better value for money, with clinical efficacy equivalent to intravenous PPIs.

Keywords: bleeding peptic ulcers; endoscopic treatment; intravenous PPIs; meta-analysis; oral PPIs; proton pump inhibitors.

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Figures

Figure 1
Figure 1
Prisma flow chart GORD, gastro‐oesophageal reflux disease; PPI, proton pump inhibitor
Figure 2
Figure 2
(A) Risk of bias graph: review of authors’ judgements about each risk of bias item presented as percentages across all included studies. (B) risk of bias summary: review of authors’ judgements about each risk of bias item for each included study. +, low risk ofbias; ?, unclear risk of bias; ‐, High risk of bias
Figure 3
Figure 3
Forest plot of recurrent bleeding. CI, confidence interval; IV, intravenous; M‐H, Mantel‐Haenszel; PPI, proton pump inhibitor
Figure 4
Figure 4
Forest plot of comparison between oral and IV PPIs for (A) need for surgery, (B) mortality and (C) EHT, need for a second endoscopic treatment. CI, confidence interval; IV, intravenous; M‐H, Mantel‐Haenszel; PPI, proton pump inhibitor
Figure 5
Figure 5
Forest plot of comparison between oral and IV PPIs for (A) need for blood transfusion and (B) length of hospital stay. CI, confidence interval; IV, intravenous; M‐H, Mantel‐Haenszel; PPI, proton pump inhibitor
Figure 6
Figure 6
Blood transfusion requirement with high‐dose oral vs. high‐dose intravenous PPI. CI, confidence interval; IV, intravenous; PPI, proton pump inhibitor; SD, standard deviation
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