Upper Gastrointestinal Bleed — Medications — Clinical Pathway: Emergency Department, ICU and Inpatient

Upper Gastrointestinal Bleed Clinical Pathway — Emergency Department, ICU and Inpatient

Medications

Medications Rationale Considerations
  • H2RA, mild
    • Famotidine
    • 0.5 mg/kg/dose PO twice daily
    • Max: 40 mg/dose
  • For mild cases, when PPI is not available
  • Dose adjustment may be warranted in renal impairment:
    • CrCl < 50 mL/min/1.73 m2
  • Tachyphylaxis
  • Less effective compared to PPIs
  • PPIs
  • PO, mild
    • 1 mg/kg/dose PO once or twice daily
    • Max:
      • Lansoprazole 30 mg/dose
      • Omeprazole 40 mg/dose
  • IV, Moderate/Severe
    • Pantoprazole
    • 1 mg/kg/dose IV twice daily
    • Max: 40 mg/dose
    • Transition to PO when clinically indicated
  • Post-endoscopy:
    • High-dose, twice-daily PPI therapy reduced further bleeding, mortality, and surgery (adult data).
  • Give oral PPI ~30 min before meals to optimize therapy
  • Consider standard-dose PPI, 1 mg/kg daily, based on endoscopic findings
  • Long-term side effects include:
    • Increased risk of infections (i.e., C. difficile)
    • Bone health abnormalities
    • Hypomagnesemia
    • Vitamin B12 deficiency
  • Consider decreasing high-dose to standard therapy; arrange follow-up and discontinue when no longer indicated
  • Erythromycin
    • 3 mg/kg IV x1 30-90 minutes before endoscopy, infused over 30-60 minutes
    • Max: 250 mg
  • Mechanism:
    • Prokinetic agent used to propel blood and clot distally from the upper GI tract and improve visualization at endoscopy, thereby improving diagnostic yield
  • Reduces further need for repeat endoscopy and length of hospitalization but does not improve clinical outcomes
    • i.e., further bleeding, mortality
 Intravenous erythromycin may cause significant phlebitis and should be administered via a high-flow vein, 24 or 22-gauge IV catheter, if possible
  • Octreotide  
    • 1 mcg/kg IV bolus, followed by 1 mcg/kg/hour continuous infusion, titrate to effect
    • Taper dose by 50% every 12 hours when no active bleeding occurs for 24 hours; may discontinue when dose is 25% of initial dose
  • Mechanism:
    • Reduces portal blood flow and intravariceal pressure; may also reduce risk of rebleeding due to nonvariceal causes. Has been reported to inhibit gastric acid secretion and reduce gastroduodenal blood flow.
      • Used primarily for bleeds secondary to portal hypertension
 May cause bradycardia, hyperglycemia