title: Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Current guidelines recommend an intravenous bolus dose of a proton pump inhibitor (PPI) followed by continuous PPI infusion after endoscopic therapy in patients with high-risk bleeding ulcers. Substitution of intermittent PPI therapy, if similarly effective as bolus plus continuous-infusion PPI therapy, would decrease the PPI dose, costs, and resource use.
  
  
  OBJECTIVE
  To compare intermittent PPI therapy with the currently recommended bolus plus continuous-infusion PPI regimen for reduction of ulcer rebleeding.
  
  
  METHODS
  Searches included MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases through December 2013; US and European gastroenterology meeting abstracts from 2009 to 2013; and bibliographies of systematic reviews.
  
  
  METHODS
  Randomized trials of patients with endoscopically treated high-risk bleeding ulcers (active bleeding, nonbleeding visible vessels, and adherent clots) comparing intermittent doses of PPIs and the currently recommended regimen (80-mg intravenous bolus dose of a PPI followed by an infusion of 8 mg/h for 72 hours).
  
  
  METHODS
  Duplicate independent data extraction and risk-of-bias assessment were performed. Data were pooled using a fixed-effects model or a random effects model if statistical heterogeneity was present.
  
  
  METHODS
  The primary outcome was rebleeding within 7 days; additional predefined outcomes included rebleeding within 3 and 30 days, need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay. The primary hypothesis, defined before initiation of the literature review, was that intermittent use of PPIs was noninferior to bolus plus continuous infusion of PPIs, with the noninferiority margin predefined as an absolute risk difference of 3%.
  
  
  RESULTS
  The risk ratio of rebleeding within 7 days for intermittent vs bolus plus continuous infusion of PPIs was 0.72 (upper boundary of 1-sided 95% CI, 0.97) and the absolute risk difference was -2.64% (upper boundary of 1-sided 95% CI, -0.28%, which is well below the predefined noninferiority margin of 3%). Risk ratios for rebleeding within 30 days and 3 days, mortality, and urgent interventions were less than 1 and mean differences for blood transfusion and hospital length of stay were less than 0, indicating that no summary estimate showed an increased risk with intermittent therapy. The upper boundaries of 95% CIs for absolute risk differences were less than 1.50% for all predefined rebleeding outcomes.
  
  
  CONCLUSIONS
  Intermittent PPI therapy is comparable to the current guideline-recommended regimen of intravenous bolus plus a continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers. Guidelines should be revised to recommend intermittent PPI therapy.
authors.affiliation: Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Hamita
authors.initials: H
authors.lastname: Sachar
authors.affiliation: Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Keta
authors.initials: K
authors.lastname: Vaidya
authors.affiliation: Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut2Section of Digestive Diseases, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven.
authors.forename: Loren
authors.initials: L
authors.lastname: Laine
mesh_terms: D006801:Humans; D007262:Infusions, Intravenous; D010437:Peptic Ulcer / Q000150:complications / Q000188:drug therapy*; D010438:Peptic Ulcer Hemorrhage / Q000188:drug therapy* / Q000209:etiology; D054328:Proton Pump Inhibitors / Q000008:administration & dosage*
chemical_list: D054328:Proton Pump Inhibitors