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We agree with Dr Gerson's insightful review. Some additional points can be made to put into perspective the findings of our cost-effectiveness analysis. In the commentary's review of the existing literature, it should be emphasized that the US pantoprazole study (Am J Gastroenterol 2006;101:1991–1999) that has been quoted looked at the use of high-dose IV proton pump inhibitors (PPI) after endoscopic hemostasis, and Khuroo (N Engl J Med 1997;336:1054–1058) studied oral high-dose of PPI administration after endoscopic diagnosis without hemostasis.

Dr Gerson is correct in suggesting that high-quality, long-term assessment of outcomes (ie, years) in peptic ulcer bleeding is currently lacking, but it may not be of such significant concern when taking into account the natural history of acute peptic ulcer bleeding. Furthermore, it is true that cost-effectiveness evaluations often employ quality-adjusted life-years (QALYs) as unit of effectiveness. Unfortunately, QALYs may not be as applicable to this condition because most of the disbenefits relate to a very short duration (≤30 days in most randomized trials, assuming that patients subsequently undergo appropriate Helicobacter eradication and/or long-term PPI prophylaxis). Indeed, it is very difficult to accurately assess such a short-lived negative impact when using QALYs that are designed to weight an experience over a patient's remaining lifespan. In fact, the use of QALYs has been questioned recently for such short durations of illness such as that of an acute peptic ulcer bleed (Health Econ 2000;9:177–180; J Clin Epidemiol 2005;58:291–303). This is why many have elected not to use QALYs in ulcer bleeding cost analyses, even though alternate measurements of effectiveness also bear limitations (Gastrointest Endosc 2008;67:1064–1066). In a recent exploratory analysis, we did proceed, however, with such an assessment and demonstrated that the use of high-dose IV pantoprazole before endoscopy would provide 1 additional QALY at a cost of $1,218,213 (Gastroenterology 2008[abstract]). Even though the conclusion in general terms remains the same, the disproportionate incremental cost-effectiveness ratio value highlights the poor interpretability of QALYs in this clinical context.

As methodologists and clinicians, we believe, based on existing data and clinical experience, that the issue is not whether the use of PPI pre-endoscopy should be administered, but rather to determine under which conditions it is more likely to be cost effective. We have thus suggested it be used in certain settings: for patients at great likelihood of bleeding from ulcers with a high-risk endoscopic lesion (such as those with a bloody nasogastric aspirate or hematemesis), and in situations when endoscopy is likely to be delayed (Gastrointest Endosc 2008;67:1064–1066). At the end of the day, however, clinicians must keep in mind that adequate resuscitation coupled with early endoscopy is likely to have a much greater impact on patient outcome than any preprocedural PPI pharmacotherapy.