Commentary on "Stress Ulcer Prophylaxis in Hospitalized Patients, Subsequent Use in Primary Care and Physicians' Opinions About Acid-Suppressive Therapy".

Acid-suppressive therapy (histamine 2 receptor antagonist [H2] or proton pump inhibitors [PPIs]) is one of the most prescribed treatments in both inpatient and outpatient settings in the United States (eg, esomeprazole, with 18.6 million prescriptions in 2014) and Europe. Increasingmedical literature data, however, have shown the appearance of serious adverse effects such as vitamin B12 malabsorption, hypomagnesemia, and the interaction of PPIs and clopidogrel in ischemic heart disease, as well as risks of potentially life-threatening conditions (eg, Clostridium difficile infection, pneumonia, spontaneous bacterial peritonitis in cirrhosis) associated with their use. Furthermore, the impact of these adverse effects linked to PPIs/H2 prescriptions, which in many cases required hospitalization, could not be measured with precision and certainty in terms of cost and quality of care. Some studies have reported a decrease in inadequate prescription of acid-suppressive therapy, but is this decrease actually occurring? Probably not. Indeed, some medical societies, including the Society of Hospital Medicine, have proposed reduction in the inappropriate use of acid-suppressive medication for stress ulcer prophylaxis (SUP) as one of the key opportunities of value of care in hospitalized patients. As such, the problem of acid-suppressive therapy overuse truly is a challenge for healthcare providers. We are not talking just about financial costs; it is also about how to change a tendency, an automation, and reduce low-value care decisions, thereby increasing the quality of healthcare systems. Indeed, interventions of high-quality care in low-risk patients on general medicine floors are one of the main areas to be improved, and clinicians’ and patients’ way of thinking about the prescription of PPIs/H2 and fears of gastrointestinal (GI) bleeding should be changed. We must move forward from a nonYevidence-based decision model (ie, no matter what disease and severity encourage patient admission to the hospital, everyone should have acid-suppressive therapy; it is a safe measure) to a selection of therapies centered around patients and their status: intensive care unit, high risk of GI complications, or low-risk patient on general medicine wards. The article by Riaz and colleagues in this month’s Southern Medical Journal highlights the complexity of this issue and its extension among in-hospital care and its continuum after discharge in the outpatient setting. The authors address important issues surrounding overtreatment for the purpose of SUP during hospitalization of low-risk patients on a general medicine ward. Most older adult patients were excluded because this population usually has a higher prevalence of comorbidities and polypharmacy. Among this older population, however, up to half of the residents in nursing facilities in the United States were prescribed PPIs, a practice that is not in agreement with current recommendations. Of note is the significant magnitude of a personal history of PPIs/H2 use in the decisions of physicians to prescribe them during hospitalization; its weight in logistic regression analysis was almost three times higher than indicated by any American Society of Health-System Pharmacists guideline for prescribing acid-suppressive therapy. Furthermore, most of these patients continued to take it 6 months after discharge, without any modification from their local general practitioner. It is plausible that the use of PPIs/H2 before admission to a hospital was initiated during a former hospitalization. As such, once the prescription for SUP is ordered at one point in the care of a Invited Commentary