It’s hard to fight this battle in the United States. It’s like hyperkalemia – where you carefully talk down the rotating IM intern from giving albuterol, terbutaline, bicarbonate, insulin, Kayexalate, and calcium to the K+ of 5.7 in your dialysis patient – and then the nephrology fellow on-call tells ’em to give it anyway. Sigh.
But, in any event, despite the lack of evidence for benefit in patient-oriented outcomes for intravenous proton-pump inhibitors in UGIB, invariably the GI fellow wants it. There’s even a suggestion of harms associated with IV PPIs in some of these studies – in addition to everything we’re learning about how gastric acidity contributes to the total body immune defense. For all its criticisms, I think NICE – the clinical effectiveness consensus group in the United Kingdom – has gotten it right for UGIB. Terlipressin, which isn’t available in the United States, appears to be beneficial in variceal bleeding. Somatostatin analogues, not included in this guideline, may or may not be beneficial, and I agree that it was appropriate for them to be excluded.
In the meantime, I’ll keep fighting the inanity, one patient and one resident at a time….