Язвенные желудочные кровотечения

[DezhDok]

Уважаемые коллеги! В Международных клинических рекомендациях по ведению пациентов с неварикозными кровотечениями из верхних отделов желудочно–кишечного тракта пишут об отсутствии показаний к назначению при этой патологии Н2-блокаторов и соматостатина. А чем обосновывается данная статистика? Покопался в сети, в библиотеке... Без эффекта... Пишут о показаниях... Может, есть у кого-нибудь ссылочка?

[Gallen]

Ну, вот, на [Ссылки доступны только зарегистрированным пользователям ] что лежало.
Может имеется ввиду, что ингибиторы протонной помпы чуть эффективнее?

[DezhDok]

Спасибо! Я понимаю, статистика-вещь упрямая... Но по русскоязычным ресурсам и по литературе идёт сочетание ИПП с соматостатином (октреотидом), либо Н2-блокаторов с ними же...

[Dr.]

Статистика - упрямая, посмотрим же на нее!

Treatment of bleeding peptic ulcers
Rome Jutabha, MD
Dennis M Jensen, MD



UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.3 is current through August 2007; this topic was last changed on June 28, 2007. The next version of UpToDate (16.1) will be released in March 2008.
ACID SUPPRESSION*—*A number of studies have investigated the role of acid suppression with an H2 antagonist or proton pump inhibitor in patients with bleeding ulcers [23-34]. A meta-analysis of 21 randomized controlled trials evaluating proton pump inhibitors for bleeding ulcers (with or without endoscopic therapy) found a significant and consistent reduction in the risk of rebleeding (OR 0.46, 95% CI 0.33-0.64) and the need for surgery (OR 0.59, 95% CI 0.46-0.76), although a benefit on mortality was not detected [35].

An illustrative trial included 240 patients with actively bleeding ulcers or ulcers with a visible vessel who were randomly assigned to intravenous omeprazole or placebo following endoscopic hemostasis [28]. Recurrent bleeding was observed significantly less often in patients receiving omeprazole (6.7 versus 22.5 percent), a finding that led to early termination of the trial. A separate analysis based upon these data suggested that the addition of intravenous omeprazole was cost-effective [36].

Another controlled trial involving 156 patients with nonbleeding visible vessels or adherent clots demonstrated that combination therapy with intravenous omeprazole plus endoscopic hemostasis was more effective at preventing rebleeding than intravenous omeprazole alone [34].

A third placebo-controlled controlled trial in patients admitted with upper gastrointestinal bleeding demonstrated that intravenous omeprazole given before an endoscopy that was performed the morning after admission reduced endoscopic signs of bleeding and the need for endoscopic hemostatic therapy [37]. (See "Approach to the adult patient with upper gastrointestinal bleeding").

In contrast, studies on H2 antagonists have generally produced disappointing results [25,29,30,38]. A meta-analysis concluded that there was a possible minor benefit with intravenous H2 antagonists in bleeding gastric ulcers but no benefit with duodenal ulcers [38]. The relative efficacy of the proton pump inhibitors may be due to their superior ability to maintain a gastric pH at a level above 6.0, and thus protect an ulcer clot from fibrinolysis [39].

Most studies evaluated intravenous omeprazole, a formulation that is not available in all countries. Although the efficacy of intravenous formulations of other proton pump inhibitors has not been studied extensively, they are probably acceptable alternatives when given in doses that are known to inhibit gastric acid secretion.

Oral dosing of proton pump inhibitors may also be an option and is less expensive [40]. A combined analysis of five studies evaluating oral dosing (with or without endoscopic therapy) found a significant reduction in the risk of rebleeding and surgery [35]. If such an approach is considered, a high dose of an oral proton pump inhibitor should probably be used. While data are limited, oral administration of a proton pump inhibitor using standard doses in the acute bleeding setting may not affect bleeding risk since it may take several days to achieve adequate acid suppression. (See "Overview and comparison of the proton pump inhibitors for the treatment of acid-related disorders").

One of the largest and most rigorously conducted controlled trials conducted in India found that a high dose of oral omeprazole (40 mg PO BID) was associated with a decreased risk of recurrent bleeding in patients who had ulcers with a visible vessel or adherent clots who did not undergo endoscopic therapy [27]. This study suggests that the theoretical limitation of oral dosing may in part be overcome by using high doses given twice daily. Another controlled trial involving patients at high risk for rebleeding suggested that patients treated with injection therapy may also benefit from oral omeprazole [41].

In contrast, studies on H2 antagonists have generally produced disappointing results [26,30,31,39]. A meta-analysis concluded that there was a possible minor benefit with intravenous H2 antagonists in bleeding gastric ulcers but no benefit with duodenal ulcers [39]. The relative efficacy of the proton pump inhibitors may be due to their superior ability to maintain a gastric pH at a level above 6.0, and thus protect an ulcer clot from fibrinolysis [41].

Summary*—*Considering the available data, the ideal pharmacologic therapy for patients with acute ulcer bleeding appears to be an intravenous proton pump inhibitor. Although omeprazole has been the most extensively studied, other intravenous formulations of proton pump inhibitors given in doses that are known to inhibit gastric acid secretion are probably acceptable alternatives. Pantoprazole and lansoprazole and esomeprazole are the only intravenous formulations available in the United States. The suggested IV pantoprazole dose is 80 mg bolus followed by 8 mg/hr infusion. If there is no rebleeding within 24 hours, the patient may be switched to oral pantoprazole 40 mg/day or omeprazole 20 mg/day. Twice daily dosing of an oral proton pump inhibitor may be a reasonable alternative if intravenous formulations are not available.

It is unlikely that an intravenous proton pump inhibitor would be of significant benefit in patients who do not have active bleeding, or other high-risk stigmata for recurrent bleeding (such as a visible vessel or adherent clots); in such patients the risk of recurrent bleeding is low. The goal of treatment in these patients (following resuscitation) should be directed at healing the ulcers and eliminating precipitating factors (such as H. pylori and NSAIDs).

SOMATOSTATIN AND OCTREOTIDE*—*Somatostatin or its long-acting analogue octreotide have a theoretical benefit in bleeding ulcer disease because they reduce splanchnic blood flow, inhibit gastric acid secretion, and may have gastric cytoprotective effects [42,43]. A clinical benefit has been described in ulcer bleeding but because of the effectiveness of endoscopic therapy, its role is generally limited to settings in which endoscopy is unavailable or as a means to help stabilize patients before definitive therapy can be performed.
Several studies have described the experience with these agents in patients with acute nonvariceal UGI hemorrhage. A meta-analysis of these trials suggested that somatostatin was associated with a reduced risk of continued bleeding (relative risk 0.53 (95 percent CI, 0.43 to 0.63)) [44]. The risk also appeared to be reduced by octreotide, although there were fewer studies. Thus, somatostatin or octreotide can be used as adjunctive therapy before endoscopy, or when endoscopy is unsuccessful, contraindicated, or unavailable [45]. The doses used in the above studies were variable; a typical dose of somatostatin was 250 micrograms given as a bolus then given hourly for three to seven days, while a typical dose of octreotide was 50 to 100 micrograms given as a bolus followed by 25 micrograms/hour for up to three days.

TREATMENT RELATED COMPLICATIONS*—*Complications can arise prior to, during, or after emergency endoscopy [46]. Complications that can occur before endoscopy include aspiration (especially in a sedated, combative, or encephalopathic patient), hypoventilation (related to oversedation), or hypotension (due to inadequate volume replacement or transfusions in addition to sedation with opiates).

Complications of endoscopic hemostasis therapy include perforation and precipitation (or worsening) of bleeding. Aggressive initial treatment or repeated applications of thermal or injection therapy may improve hemostasis, but also increase the risk of treatment-induced complications. Thus, predetermined limits (volume of injection solution, total treatment pulses, and total energy delivered) should be set and not exceeded for each technique, in order to minimize the risk of complications. We usually do not exceed 30 mL of epinephrine (1:10,000 dilution) injection or more than five pulses.

[DezhDok]

Спасибо! Я тоже не сомневался (да и убедился), что сандостатин (октреотид) прекрасно работает на кровотечениях... Но вот налетел на эти Канадские Международные рекомендации...