Are there indications for intravenous acid-inhibition in the prevention and treatment of upper GI bleeding?

Administration of acid-inhibiting drugs in the prevention of stress ulcer b leeding is based on the hypothesis that pepsin activity is pH-dependent. In the treatment of peptic ulcer bleeding, acid-inhibition is based on the hy pothesis that clot formation and clot lysis depend on intraluminal pH. Medi cations used in the prophylaxis of stress ulcer bleeding comprise antacids, sucralfate, H-2-receptor antagonists and proton pump inhibitors (PPIs). Tw o studies show that prophylaxis with ranitidine is more effective than prop hylaxis with sucralfate. PPIs give a more predictable and sustained pH cont rol during prolonged dosing than ranitidine. Two trials show that patients who receive omeprazole run a significantly lower risk of bleeding than pati ents receiving ranitidine. The optimal initial treatment for bleeding pepti c ulcers in patients with active bleeding or non-bleeding visible vessel is endoscopic therapy. Among patients with non-bleeding visible vessels or ad herent clots who do not undergo endoscopic therapy, acid-inhibition with PP Is may significantly reduce rebleeding rate and need for surgery. After end oscopic therapy acid-inhibition with PPIs may have a beneficial effect on h emostasis. One direct comparative trial showed no significant difference in clinical outcomes between patients whether treated with high-dose or low-d ose PPI. The use of multiple medications to treat concurrent conditions in ICU patients or bleeding peptic ulcer patients increases the risks of clini cally important metabolic drug interactions. More recently developed PPIs a re less dependent on CYP2C19 and probably have a lower potential for metabo lic drug interactions. For both indications the optimal dose PPI has to be established.