Intravenous Proton Pump Inhibitors An Evidence-Based Review of Their Use in Gastrointestinal Disorders

Conditions requiring inhibition of acid secretion, such as gastro-oesophageal reflux disease or peptic ulcers, are very common and their prevalence is expected to rise as they are seen predominantly in the elderly. The general basis of treatment with antisecretory agents is to maintain gastric pH >4 for a substantial proportion of the 24-hour cycle. Among the drugs available to inhibit acid secretion, proton pump inhibitors (PPIs) have been shown to have the best benefit-risk ratio and have been used widely. Intravenous administration of a PPI provides gastric acid suppression faster than oral administration does. Whereas some indications for the use of intravenous PPIs are widely known, mostly for acute management of peptic ulcer bleeding, there are some controversies surrounding their use in other conditions such as stress-induced mucosal damage. There is still a need to define the best schedule for intravenous PPI administration (i.e. bolus infusion or constant infusion), the optimal time to switch from intravenous to oral administration and the choice of which agent is best. In most of the clinical scenarios where PPIs are recommended, they can be administered via either oral or enteral routes, unless the patient is nil by mouth. Since there are no head-to-head comparisons of the different intravenous PPIs available worldwide (omeprazole, lansoprazole, pantoprazole and esomeprazole), the rule might be to choose the drug with the best proven efficacy in each specific condition. Indeed, the key difference between them, the ability to reach and to maintain a threshold gastric pH, might not necessarily translate into clinically significant differences.