doi:10.1111/j.1440-1746.2006.04292.x 716 Journal of Gastroenterology and Hepatology 21 (2006) 716–721 © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd Blackwell Publishing AsiaMelbourne, AustraliaJGHJournal of Gastroenterology and Hepatology0815 93192006 Blackwell Publishing Asia Pty Ltd200621716721Original Article Pantoprazole in bleeding peptic ulcersSA Zargar et al. GASTROENTEROLOGY Pantoprazole infusion as adjuvant therapy to endoscopic treatment in patients with peptic ulcer bleeding: Prospective randomized controlled trial Showkat Ali Zargar, Gul Javid, Bashir Ahmad Khan, Ghulam Nabi Yattoo, Altaf Hussain Shah, Ghulam Mohammad Gulzar, Jaswinder Singh Sodhi, Sheikh Abdul Mujeeb, Mushtaq Ahmad Khan, Nisar Ahmad Shah and Hakim Mohamad Shafi Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India Abstract Background and Aim: Following successful endoscopic therapy in patients with peptic ulcer bleeding, rebleeding occurs in 20% of patients. Rebleeding remains the most impor- tant determinant of poor prognosis. We investigated whether or not administration of pantoprazole infusion would improve the outcome in ulcer bleeding following successful endoscopic therapy. Methods: In this double-blind, placebo-controlled, prospective trial, patients who had gastric or duodenal ulcers with active bleeding or non-bleeding visible vessel received combined endoscopy therapy with injection of epinephrine and heater probe application. Patients who achieved hemostasis were randomly assigned to receive pantoprazole (80 mg intravenous bolus followed by an infusion at a rate of 8 mg per hour) or placebo for 72 h. The primary end-point was the rate of rebleeding. Results: Rebleeding was lower in the pantoprazole group (8 of 102 patients, 7.8%) than in the placebo group (20 of 101 patients, 19.8%; P = 0.01). Patients in the pantoprazole group required significantly fewer transfusions (1 ± 2.5 vs 2 ± 3.3; P = 0.003) and days of hospi- talization (5.6 ± 5.3 vs 7.7 ± 7.3; P = 0.0003). Rescue therapies were needed more fre- quently in the placebo group (7.8% vs 19.8%; P = 0.01). Three (2.9%) patients in the pantoprazole group and eight (7.9%) in the placebo group required surgery to control their bleeding ( P = 0.12). Two patients in the pantoprazole group and four in the placebo group died ( P = 0.45). Conclusion: In patients with bleeding peptic ulcers, the use of high dose pantoprazole infusion following successful endoscopic therapy is effective in reducing rebleeding, transfusion requirements and hospital stay. © 2006 Blackwell Publishing Asia Pty Ltd Introduction Despite remarkable progress in the treatment of chronic peptic ulcer disease, acute gastroduodenal ulcer bleeding remains a therapeutic challenge with significant morbidity and mortality. Endoscopic therapy using injection or thermal methods signifi- cantly reduces rebleeding, the need for surgery and mortality in patients with peptic ulcer bleeding (PUB), and is now recom- mended as the first hemostatic modality of choice for these patients. 1 Although this therapy achieves successful hemostasis in more than 90% of patients, unfortunately rebleeding occurs in 10– 30% of patients, 2–5 with an average of 21%. 6 Because rebleeding has been recognized as the single most important adverse prognos- tic factor contributing to morbidity and mortality, 7,8 it is likely that further improvements in the outcome will be aimed at preventing rebleeding. Gastric acidity may play an important role in the pathogenesis of rebleeding. Both acid and pepsin may produce adverse effects on coagulation by interfering with the intrinsic and extrinsic coagulation system, fibrinogen polymerization, and platelet aggregation. 8,9 Numerous trials of H 2 receptor antagonists have not consistently shown a significant benefit in such patients. 10,11 How- ever, two recent reviews of the use of a high-dose of omeprazole in patients with PUB concluded that it improves the outcome. 12,13 Key words endoscopic hemostasis, pantoprazole, peptic ulcer bleeding, peptic ulcer rebleeding, proton pump inhibitors, randomized trials. Accepted for publication 30 November 2004. Correspondence Dr Showkat Ali Zargar, Professor and Head, Department of Gastroenterology, Sher-i- Kashmir Institute of Medical Sciences., PO Box 27; Soura Srinagar, Kashmir, India. Email: showkatzargar@yahoo.com