Reply To: Gastroprotectants: Taking the acid out of the suppression
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Hope you are safe and well. Sorry about the delay in getting back to you. I have tried to answer under your questions below:
1. You mentioned giving PPI’s one hour before food. Is this because it’ll limit the acid wave associated with the following meal and therefore it’ll be more effective? Or does the food inhibit the absorption of the drug? If food limits absorption, then would time of administration matter if you were giving it IV? Does it simply take time to work regardless of route of administration?
Acid secretion is activated by ingestion of a meal, and PPI effectiveness depends on the extent of activation of acid secretion at the time of drug administration. This is not about food inhibiting drug absorption. The PPIs are most effective when taken shortly before a meal (30‐45 minutes) or with a meal. I often mention 1 hour to owners as it seems a more practical time for them to remember. Ultimately giving it with food would be fine too. Effectiveness in people is compromised if taken without a meal. This paper is helpful:
The drug will take time to work regardless of how you administer the drug. The principle about the acid activation will be the same when giving the drug IV. However, it is likely that patients having it IV are not eating. In this situation I would give regardless and transition to oral when eating.
2. I was recently questioned about not using PPI’s intravenously in cats because the formulary only says per os. Is there actually a contraindication to giving them this way in cats?
You can give IV PPI’s in cats. I am not aware of any specific contraindications. All use would be off licence obviously.
3. As the absorption of PPI’s in cats may be affected when given orally. Would it be better to puncture the capsules before giving them, to allow liquid to penetrate them and increase the dissolution of the capsule? Or would the benefit of no capsule offset the decrease in efficacy of being given with food?
I hope I have not been misleading will by before food recommendation. Again, the point is definitely not that the food will significantly affect absorption, it is more about acid activation by food and PPI’s being more effective at this point. As per the human studies the PPI’s effect was actually diminished with no food given. The question about the capsule etc is a good one. There definitely is a huge amount of variability with the capsule formulations and the differences in absorption with cats. At the moment I don’t think we know enough, so I would leave capsules as they are for now.
4. I appreciate the point of a PPI and sucralfate, not being better than monotherapy with a PPI for gastric ulceration. However, would you consider both in cases of haemorrhagic gastroenteritis where it is presumed to be more distal?
Both of these drugs are unlikely to have any effect beyond the duodenum. Cases of haemorrhagic gastroenteritis will have most of their pathology in the distal intestine. again, neither drug will have significant impact here. The pathogenesis of this mucosal irritation is also different and will not benefit from pH modification.
5. Would you consider TXA use in particularly severe HGE cases?
This is a really interesting question. The answer is possibly. I would only consider if the PCV was dropping to the point where the loss of blood was going to become a problem/transfusion dependant. I think it is unusual for HGE cases to get to that level with blood loss.
6. Is TXA being used in cats and if so, is it the same dose as per dogs?
There is much less data but TXA OK for cats and same dose as dogs.
Hope that helps and hope you are safe and well.