Authors' objectives:

"The objectives were as follows: To evaluate the clinical effectiveness and cost-effectiveness of proton pump inhibitors (PPIs) in the prevention and treatment of acute UGI haemorrhage To evaluate the clinical effectiveness and cost-effectiveness of PPI therapy, compared with H2-receptor antagonist (H2RA), Helicobacter pylori eradication (in infected patients) or no therapy, for the prevention of first and/or subsequent bleeds among patients who continue to use non-steroidal anti-inflammatory drugs (NSAIDs) To evaluate the clinical effectiveness of PPI therapy, compared with H2RA, H. pylori eradication (in infected patients) or no therapy, for the prevention of subsequent bleeds in patients who had previously experienced peptic ulcer bleeding." (from executive summary)

Authors' recommendations: Conclusions PPI treatment compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings. It also consistently reduces rates of re-bleeding and the need for surgical intervention. PPI treatment initiated prior to endoscopy in UGI bleeding significantly reduces the proportion of patients with SRH at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with EHT for those with major SRH, is likely to be the most cost-effective. Treatment of H. pylori infection is more effective than antisecretory therapy (with or without long-term maintenance antisecretory therapy) in preventing recurrent bleeding from PU. H. pylori eradication alone or H. pylori eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies for preventing bleeding ulcers among H. pylori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective. Implications for healthcare No specific recommendation either for or against PPI use before endoscopy can be made. PPI treatment should be administered to patients with endoscopically documented PU bleeding. Based solely on the results of our meta-analysis, no specific conclusions can be drawn with regard to PPI dose or mode of administration. Nevertheless, if an oral PPI is used, the dose should be at least twice the standard clinical dose for that PPI. Based on the results of our economic modelling, the strategy of administering oral PPI both before and after endoscopy, with EHT for those with active bleeding or a non-bleeding visible vessel, is likely to be the most cost-effective. It is suggested that H. pylori-infected NSAID users should receive appropriate eradication treatment, followed by misoprostol, at least 200 mg twice daily. If misoprostol is not tolerated, it should be substituted for standard clinical dose PPI. The above strategy is likely to be the most cost-effective.

Authors' methods: Review

Project Status: Completed

URL for project: http://www.hta.ac.uk/1385

Year Published: 2007

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

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