Acid-suppression meds overused in ICU

Gordon Guyatt and Deborah Cook’s recent New England Journal of Medicine review of prophylaxis for upper gastrointestinal bleeding among hospitalized patients explains that not only is acid suppression commonly used without indication in the intensive care unit (ICU) and medical wards, but these medications are frequently continued after discharge. For example, studies have shown that ~60% of patients transferred from the ICU to the wards were continued on prophylactic acid suppression without indication.

The article also reviews some of the potential adverse effects of unnecessary acid suppression, including chronic kidney disease, osteoporosis, and infections. We agree with their Slow Medicine conclusion that prophylactic acid suppression is often “used for critically ill patients at low risk [of bleeding] and for many hospitalized patients who are not critically ill and have a very low risk of bleeding … For low-risk patients in the ICU, in medical and surgical units … use of acid suppression in the absence of a clear indication for it may confer a net harm.”

The overuse of acid-suppressing medications is not limited to the inpatient setting, however. A series of studies have also demonstrated that roughly 50% of outpatients on chronic proton pump inhibitors (PPIs) do not have indications for these medications.

So the question arises: how should we approach “deprescribing” PPIs? Anecdotally, we have not had much success with simply recommending that patients stop cold turkey. In part this is due to rebound acid hypersecretion, which begins ~2 weeks after stopping PPIs and can last for months until acid production returns to normal. Fortunately, the Canadian Family Physician recently published an evidence review with some tips. While the authors find there is little solid evidence to recommend one approach over another when deprescribing PPIs, what is clear is that we should consider several options, including a gradual dose decrease, spacing out dosing to every other day, or switching to “as needed” use.

Another option is a “step-down” approach in which patients are transitioned to H2 blockers or antacids; there is some evidence from the DIAMOND trial to support this strategy. These options are clearly laid out for clinicians in a complementary review by the Canadian Therapeutics Initiative.

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