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American Journal of Critical Care. 2008;17: 404
Copyright © 2008 by the American Association of Critical-Care Nurses.
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LETTERS

Skeptical That Pantoprazole Dose Can Prevent Bleeding

By Hwai-Jeng Lin, MD, FACG and Jai-Jen Tsai, MD. Lotung Pohai and Taipei, Taiwan

We read with interest the article titled "Famotidine Versus Pantoprazole for Preventing Bleeding in the Upper Gastrointestinal Tract of Critically Ill Patients Receiving Mechanical Ventilation."1 In this retrospective study, Ojiako et al conclude that famotidine and pantoprazole are similarly effective for preventing bleeding in the upper gastrointestinal tract in patients receiving mechanical ventilation.

Several points need to be discussed. This study was retrospective and had different sample sizes in the 2 groups (522 for famotidine and 95 for pantoprazole). Is it possible that doctors used pantoprazole for those cases that were more severe? This selective use could perhaps be a contributing factor to the greater number of bleeding patients in the pantoprazole group.

The dose and route of pantoprazole may not have been sufficient to prevent bleeding in this study. A stable blood clot in a peptic ulcer is crucial to hemostasis.2,3 In a low-pH environment, platelet dysfunction has been observed. In addition, pepsin can lyse the clots and induce bleeding thereafter.3,4 Therefore, to prevent bleeding, intragastric pH should be maintained at greater than 6. However, with 40 mg pantoprazole orally,5 which was the dose used in the study by Ojiako et al, the median 24-hour intragastric pH is 3.8.

In an earlier study,6 we used a large dose of intravenous proton pump inhibitors (PPIs) and elevated intragastric pH to greater than 6, and as a result rebleeding could be prevented after endoscopic therapy. Lau et al7 also had a similar observation. If we decrease the intravenous dose of PPI to 80 mg daily, the rebleeding rate will be increased to 21.2% (as compared with 9% when 160 mg PPI was administered intravenously daily).8 Even before endoscopic therapy, a large dose of PPI is beneficial for patients with bleeding in the upper part of the gastrointestinal tract.9 Therefore, oral administration of 40 mg of pantoprazole daily, as done in the study by Ojiako et al, is not enough to prevent bleeding.

FINANCIAL DISCLOSURES
None reported.

REFERENCES

  1. Ojiako K, Shingala H, Schorr C, et al. Famotidine versus pantoprazole for preventing bleeding in the upper gastrointestinal tract of critically ill patients receiving mechanical ventilation. Am J Crit Care. 2008;17(2):142–147.[Abstract/Free Full Text]
  2. Green FW, Kaplan MM, Curtis LE, et al. Effect of acid and pepsin on blood coagulation and platelet aggregation. Gastroenterology. 1978;74:38–43.[Medline]
  3. Low J, Dodds AJ, Biggs JC. Fibrinolytic activity of gastroduodenal secretions: a possible role in upper gastrointestinal haemorrhage. Thromb Res. 1980;17:819–830.[Medline]
  4. Patchett SE, Enright H, Afdhal N, et al. Clot lysis by gastric juice: an in vitro study. Gut. 1989;30:1704–1707.[Abstract/Free Full Text]
  5. Fitton A, Wiseman L. Pantoprazole, a review of its pharmacological properties and therapeutic use in acid-related disorders. Drugs.1996;51:460–482.[Medline]
  6. Lin HJ, Lo WC, Lee FY, et al. A prospective randomized comparative trial showing that omeprazole prevents rebleeding in bleeding peptic ulcer patients after successful endoscopic therapy. Arch Intern Med. 1998;158:54–58.[Abstract/Free Full Text]
  7. Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343:310–316.[Abstract/Free Full Text]
  8. Lin HJ, Lo WC, Cheng YC, et al. Role of intravenous omeprazole in patients with high-risk peptic ulcer bleeding after successful endoscopic epinephrine injection: a prospective randomized comparative trial. Am J Gastroenterol. 2006; 101:500–505.[Medline]
  9. Lau JY, Leung WK, Wu JC, et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med. 2007;356:1631–1640.[Abstract/Free Full Text]




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