Comment on “High‐Dose Oral Omeprazole Versus Continuous Intravenous Pantoprazole in Patients With High‐Risk Peptic Ulcer Bleeding”

Dear Editor,

1.

The trial by Sriyudthsak et al. is attractive because it asks a question that is simple at the bedside but not simple in evidence: After successful endoscopic hemostasis for high‐risk peptic ulcer bleeding, can we safely stop thinking of continuous intravenous proton pump inhibition as the automatic next step? [1] An oral strategy has obvious practical advantages. It avoids an infusion, may reduce venous access use, and is easier for wards with limited nursing capacity. For these reasons, the study is useful. Still, I think its findings are better used to refine patient selection than to support a broad change in practice.

The low rebleeding rate in both arms is encouraging, but it also makes the result fragile. At 72 h, rebleeding occurred in 1.6% of patients receiving oral omeprazole and 4.8% receiving intravenous pantoprazole [1]. This direction is reassuring for oral therapy, yet the confidence interval around the risk difference was wide (−11.6% to 4.6%). A reader may therefore reasonably conclude that oral therapy is feasible in selected patients but not that the two strategies are clinically interchangeable. This is an important difference. In upper gastrointestinal bleeding, a small early excess of rebleeding can matter, particularly in patients who present with shock, need transfusion, or have ulcers that were difficult to secure endoscopically. Current ACG and ESGE guidelines support high‐dose proton pump inhibitor therapy after endoscopic hemostasis and allow continuous or intermittent regimens, but they do not remove the need for bedside risk stratification before choosing an immediate oral‐only approach [2, 3].

The gastric pH data add a useful mechanistic layer, although they do not fully answer the same clinical question. Monitoring was completed in fewer than half of the patients and was performed during 48–72 h after treatment initiation [1]. By that time, the most anxious period for many clinicians has already passed. What would be most helpful is acid‐control information during the first day after hemostasis, when clot stability is most vulnerable and when rescue endoscopy is most likely to be considered. The oral group had a numerically higher median percentage of time with pH above 6, but the dispersion was wide. In practice, oral drug exposure may also be influenced by vomiting, delayed gastric emptying, meal timing, Helicobacter pylori status, and CYP2C19 metabolism. These are not minor details if the proposed strategy depends on early and reliable oral absorption.

One other point is worth separating. The comparison was not only oral versus intravenous treatment. It was also omeprazole 40 mg twice daily versus pantoprazole 8 mg/h continuously [1]. Similar outcomes therefore cannot be attributed to route alone. Previous meta‐analytic evidence has suggested that intermittent proton pump inhibitor therapy may be comparable with continuous infusion after endoscopic therapy for high‐risk bleeding ulcers, but that question is not identical to immediate oral treatment [4]. Future studies could be more informative if they specify an oral pathway in advance and report outcomes by practical clinical strata: forrest classification, hemodynamic status, transfusion requirement, antithrombotic exposure, ulcer size and site, certainty of hemostasis, and ability to tolerate oral medication.

Thus, the strongest message of this trial may be a pragmatic one. High‐dose oral omeprazole is a plausible early option for stable patients after effective hemostasis, especially where avoiding infusion has real value. Before it is adopted as a routine substitute for continuous intravenous therapy in high‐risk peptic ulcer bleeding, however, a larger noninferiority trial should test prespecified eligibility criteria, early pH monitoring, standardized rescue rules, cost, length of stay, and patient‐centered outcomes. Until then, I would regard oral high‐dose proton pump inhibition as a selective de‐escalation strategy rather than a general replacement for intravenous therapy.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.