does it matter whether you give a patient IV or PO PPI?

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Patients who require IV PPI are sick ones. ICU patients who need IV PPI because of stress ulcers, bleeding ulcers, or inability to take PO *do* benefit from the IV form. IV PPI is actually only FDA-approved for complicated erosive esophagitis, Zollinger-Ellison syndrome, and patients who are unable to take PO. That’s it.

However, the practice that I’ve seen is to stick every critically ill patient or patient with any kind of GI history on an IV PPI…just because. What is the evidence behind using IV PPI vs the PO form?

The argument for using IV PPI is that the critically ill gut is one that is less likely to absorb oral medications and IV will get around this problem. Theoretically, PPI boluses are more effective because they act on stimulated parietal cells so patients should be “loaded” with a bolus and if they require continuous infusion, say, for a bleeding ulcer, then that should be started. (There is no evidence that continuous infusion is superior to IV boluses twice a day, however.)

The reason we wish we could do away with IV PPI for most patients is because they are associated with some pretty serious side effects. They have been shown to increase the risk of aspiration pneumonitis, spontaneous bacterial peritonitis, and interact more with drugs that are metabolized by certain CYP450 enzymes. Patients are often put on “routine” PPI prophylaxis and then discharged on a PPI…even if they never needed it in the first place.

However, strong evidence for going IV or PO is sorely lacking. A recent study by Tsoi et al showed no significant difference between IV and PO PPI in rebleeding, reintervention, or outcomes in post-endoscopy patients. However, their meta-analysis was stymied by the relatively few, small, and varied studies that had been done.

In summary, one review concludes:

The use of IV PPI as prophylaxis against stress-related mucosal injury needs to be judicious. Routine prophylaxis is not cost-effective, and may subject patients to unnecessary side effects. It should be reserved for patients who are at higher risk of developing stress related ulcers. Acid-suppressive therapy is often inappropriately continued post ICU discharge, and even beyond hospital discharge in the community

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