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Selected pharmacologic options for a child with upper gastrointestinal bleeding

Selected pharmacologic options for a child with upper gastrointestinal bleeding
  Dose Category
Acid suppression (IV)*
Esomeprazole Intermittent dosing:
  • Infants: 0.5 to 1 mg/kg/dose IV once daily
  • Children 1 to 17 years:
    • <55 kg: 10 mg IV once or twice daily
    • ≥55 kg: 20 mg IV once or twice daily
  • Adults: 80 mg IV once, followed by 40 mg IV twice daily

Continuous IV infusion*[1]:

  • 1 mg/kg IV bolus (maximum 80 mg), followed by infusion of 0.1 mg/kg/hour (maximum 8 mg/hour)
 PPI
Omeprazole (IV preparation not available in the United States) Children and adolescents[2]:
  • 1 mg/kg IV daily in 1 or 2 divided doses (maximum 80 mg daily); reported effective dose range 0.2 to 3.5 mg/kg IV daily in 1 or 2 divided doses
 PPI
Adults:
  • 40 mg IV twice daily
Pantoprazole Intermittent dosing:
  • Children and adolescents:
    • <40 kg: 0.5 to 1 mg/kg IV once or twice daily
    • ≥40 kg: 20 to 40 mg IV once or twice daily
  • Adults: 80 mg IV once, followed by 40 mg IV twice daily

Continuous IV infusion*[1]:

  • 1 mg/kg IV bolus (maximum 80 mg), followed by an infusion of 0.1 mg/kg/hour (maximum 8 mg/hour)
 PPI
Acid suppression (oral)Δ◊
Esomeprazole Infants 1 month to 1 year (orally once daily):
  • 3 to 5 kg: 2.5 mg
  • 5 to 7.5 kg: 5 mg
  • 7.5 to 12 kg: 10 mg

Children 1 to 11 years (orally once or twice daily):

  • Weight <20 kg: 10 mg
  • Weight ≥20 kg: 10 mg or 20 mg

Children ≥12 years and adults:

  • 40 mg twice daily initially, followed by 40 mg once daily (as a maintenance dose, once risk of recurrent bleeding is low)
 PPI
Omeprazole Children and adolescents:
  • Weight-based dosing:
    • 1 to 3 mg/kg orally daily[3] (maximum 80 mg daily) in 1 or 2 divided doses
  • Fixed dosing:
    • 3 to <5 kg: 2.5 mg once or twice daily
    • 5 to <10 kg: 5 mg once or twice daily
    • 10 to <20 kg: 10 mg once or twice daily
    • ≥20 kg: 20 mg once or twice daily
 PPI
Adults:
  • 40 mg orally twice daily initially, followed by 40 mg once daily (maintenance dose, once risk of recurrent bleeding is low)
Pantoprazole Children 5 to 11 years:
  • Weight 15 to 39 kg: 20 mg orally once daily
  • Weight ≥40 kg: 40 mg orally once daily

Children ≥12 years and adults:

  • 40 mg orally twice daily initially, followed by 40 mg once daily (as a maintenance dose, once risk of recurrent bleeding is low)
 PPI
Vasoactive therapy for variceal bleeding
Octreotide Children and adolescents:
  • 1 to 2 micrograms/kg IV bolus (maximum 50 micrograms) over 30 minutes, followed by 1 to 2 micrograms/kg/hour as a continuous IV infusion titrated to response§ (maximum 50 micrograms per hour)[4]; initial bolus may be repeated once in the first hour if needed
 Somatostatin analog
Adults:
  • 50 microgram IV bolus followed by a continuous IV infusion of 50 micrograms/hour; initial bolus may be repeated once in the first hour if needed
Antiemetics
Ondansetron¥ Children ≥6 months:
  • Oral (disintegrating tablet or oral solution): Given as a single dose; may repeat every 6 to 8 hours as needed to control vomiting*
    • Weight-based dosing:
      • 0.15 mg/kg (maximum dose 8 mg)
    • Fixed dosing:
      • Weight 8 to 14 kg: 2 mg
      • Weight 15 to 30 kg: 4 mg
      • Weight >30 kg: 8 mg
  • IV: 0.15 mg/kg/dose as a single dose (maximum dose 8 mg); may repeat every 6 to 8 hours as needed to control vomiting
  • IV administration should be limited to those unable to tolerate oral administration
 5-HT3 antagonist
Adults:
  • 4 to 8 mg (oral, IV) as a single dose; may repeat every 6 to 8 hours as needed
Pharmacologic options for a child with UGIB. Acid suppression is appropriate for most children with clinically significant UGIB. Children with signs of significant bleeding and active blood loss (eg, hypovolemia, cardiac instability) require immediate stabilization and should be transferred to a pediatric intensive care unit if possible. In general, initial pharmacologic treatment of serious UGIB includes the use of high-dose or continuous IV PPI therapy for acid suppression, which is continued during the period of highest risk for rebleeding (eg, first 3 days). Vasoactive agents may be helpful for selected cases of vascular bleeding (eg, from esophageal varices).

5-HT3: 5-hydroxytryptamine type 3 receptor; H2RAs: histamine 2 receptor antagonists; IV: intravenous; PPI: proton pump inhibitor; UGIB: upper gastrointestinal bleeding.

* In high-risk UGIB due to peptic ulcers, IV PPI (preferably as a continuous infusion) is continued for approximately 3 days while the risk of rebleeding is greatest. IV H2RAs (eg, famotidine) are less effective than PPIs in controlling bleeding of peptic ulcers, based on data in adults. For additional information, refer to topic reviews on management of peptic ulcers.

¶ Continuous dosing of IV esomeprazole and pantoprazole is not well established; this protocol has been used and reported by some centers[1].

Δ Oral PPI administration follows IV PPI therapy in high-risk UGIB or may be used initially for clinically stable, low-risk patients. Optimally, orally administered PPIs are given once daily before the first meal of the day (or if given twice daily, prior to the first meal and the evening meal). Other oral PPIs may be used, including rabeprazole and lansoprazole. For dosing, refer to pediatric drug monographs or topic reviews on gastroesophageal reflux disease in children and adolescents.

◊ In general, the pediatric dose should not exceed the higher end of the adult dose range. On an mg/kg basis, doses of some of the PPIs needed for children are greater than those for adolescents and adults to obtain a similar degree of acid suppression.

§ Octreotide doses of up to 5 micrograms/kg/hour may be needed for circulatory support in severe acute UGIB (in addition to transfusion)[5].

¥ For ondansetron, oral administration is generally preferred if tolerated because it has a smaller effect on the QT interval compared with IV[6]. However, IV administration at the above dose is generally safe in patients without other risk factors for QT prolongation[7].

References:
  1. Neidich GA, Cole SR. Gastrointestinal bleeding. Pediatr Rev 2014; 35:243.
  2. Owensby S, Taylor K, Wilkins T. Diagnosis and management of upper gastrointestinal bleeding in children. J Am Board Fam Med 2015; 28:134.
  3. Hassall E, Israel D, Shepherd R, et al. Omeprazole for treatment of chronic erosive esophagitis in children: A multicenter study of efficacy, safety, tolerability and dose requirements. J Pediatr 2000; 137:800.
  4. Eroglu Y, Emerick KM, Whitingon PF, Alonso EM. Octreotide therapy for control of acute gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr 2004; 38:41.
  5. Mas E, Borrelli O, Broekaert I, et al. Drugs in focus: Octreotide use in children with gastrointestinal disorders. J Pediatr Gastroenterol Nutr 2022; 74:1.
  6. Freedman SB, Uleryk E, Rumantir M, Finkelstein Y. Ondansetron and the risk of cardiac arrhythmias: A systematic review and postmarketing analysis. Ann Emerg Med 2014; 64:19.
  7. Misirlioglu HY, Ince EO, Akkas M, et al. The effect of intravenous ondansetron on QT interval in the emergency department. Am J Emerg Med 2024; 85:7.
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