急診短講012 ─ 關於High dose PPI

 急診短講012 ─ 關於High dose PPI

 

針對非靜脈曲張的上消化道出血，常聽到要使用高劑量的PPI，至於高到多少，來看一下證據吧！

 

【先講結論：針對尚未執行上消化道鏡之前，有大量上消化道出血的病人，給予80mg PPI是個合理的選擇。做完上消化道鏡之後，針對非靜脈曲張的上消化道出血，給予PPI infusion (8 mg/hr for 3 days) 和 intermittent PPI (40 mg twice daily) 之間，沒有很大的差異。運用之妙，存乎一心。】

 

本文僅針對高風險的出血性潰瘍，包括 active bleeding (I), nonbleeding visible vessels (IIa, NBVV), and adherent clots (IIb) [ () 內為 forrest classification]

也就是P = high-risk bleeding ulcers (active bleeding, nonbleeding visible vessels, and adherent clots)

 

主要引用Review: An update on the management of non-variceal upper gastrointestinal bleeding. [Gastroenterol Rep (Oxf). 2023 Mar 20:11:goad011.]

 

ACG guidelines [Am J Gastroenterol 2021;116:899–917.]

Based on 7 RCTs and high-quality evidence

I= high-dose PPI (defined as ≥80 mg daily for 3 days)

C= placebo or no treatment (沒有使用PPI或其他治療，這..沒有武德)

O= further bleeding (RR 0.43, 95% CI 0.33–0.56),

mortality (RR 0.41, 95% CI 0.22–0.79), surgery (0.42, 95% CI 0.25–0.71)

跟不治寮組比較，高劑量PPI顯然有壓倒性好處！

 

[JAMA Intern Med. 2014 Nov;174(11):1755-62.]

meta-analysis of 13 RCTs

I= Intermittent PPI therapy (40mg twice daily)

C= PPI infusion (80 mg bolus followed by 8 mg/hour infusion for 3 days)

O: all comparable

rebleeding within 7 days, RR 0.74 (0.52-1.06) 

need for urgent intervention, mortality, RBC transfusion, length of hospital stay.

跟高劑量PPI組比較，間歇性PPI組治療，有可匹配的效果！

 

[Aliment Pharmacol Ther 2013;38:721–8.]

meta-analysis of 13 RCTs comparing these two PPI regimens in patients with confirmed high-risk bleeding ulcers. 

I= Intermittent PPI therapy (40mg twice daily)

non-inferior to

C= PPI infusion (80 mg bolus followed by 8 mg/hour infusion for 3 days)

O: rebleeding, mortality, and urgent interventions.

間歇性PPI組治療效果，不劣於高劑量PPI組

  

 

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