The War on Acid: Is an Ounce of Prevention Really Worth a Pound of Cure?
So you were recently admitted to the hospital for a routine procedure and left with a little parting gift… a prescription for Nexium. You’re not alone. Studies estimate that between 40 and 70 percent of hospital inpatients receive some form of acid-suppressive medication during their hospital stay. Although for many it is the first time they have ever taken this type of drug, roughly half will leave the hospital with a prescription. But why? When a friend of mine was recently admitted to the ICU for surgery, among the other drugs she was given was the recognizable little purple pill. “Why do I need that, I don’t have heartburn?” she asked. The nurse’s reply? “Oh, we give that to everyone. It’s hospital policy.”
In fact, the widespread use of acid-suppressive medication began in ICUs, where early studies found it to be beneficial. But now even non-ICU hospital patients are routinely prescribed proton pump inhibitors (“PPIs”) and H2-recepter antagonists. Dr. Shoshana Herzig, Harvard Medical School professor and lead investigator on a study conducted at Beth Israel Deaconess Medical Center in Boston says it is a case of “mission creep,” where a seemingly good idea is given unreasonably broad application. Clinicians extrapolated the data from the early ICU studies to the broader hospital population, apparently thinking that what was good for the goose was good for the gander.
In the Beth Israel study, researchers tracked nearly 80,000 patients for incidents of nosocomial gastrointestinal bleeding (“GI bleeding”) and acid suppression outside of the ICU setting. Published in the February 14, 2011 issue of the Archives of Internal Medicine, the study found that GI bleeding generally occurs in only 0.29 percent of admissions. Nevertheless, 59 percent of non-critically ill patients were given acid-suppressive medication. While the use of acid suppressive medication was indeed protective — resulting in a 37 percent reduction in the risk of bleeding — given the very low incidence of the complication it was intended to prevent, the researchers determined that 770 patients would need to be treated with acid-suppressive medication to prevent a single episode of GI bleeding.
So the drugs may not be necessary, you say, but what’s the harm? Plenty. The study also noted that certain risks associated with the drugs in the hospital setting, including an increased risk for contracting community-acquired pneumonia (a 30 percent increase according to one article) or the infection Clostridium difficile (“C. difficile”), outweighed any benefit for most patients. These risks are elevated when acid-suppressing drugs are used because gastric acidity constitutes a major defense mechanism against ingested pathogens. Acid-suppression can equal lowered defenses. For a patient already sick and in the hospital, this risk may not be worth taking.
Finally, one cannot help but wonder if financial motives are also at play here. The Consumers Union stated in a policy brief on the prevalence of hospital-acquired C. difficile infections that “[m]ajor financial incentives for pharmaceutical companies to market these drugs are behind this dangerous trend.” Indeed, that the drugs’ manufacturers are prone to aggressively market these drugs is already established in other contexts. With direct-to-consumer advertisement responsible for 12 percent of the increase in prescription drug sales in 2000, proton pump inhibitors (“PPI’s”) like Nexium and Prilosec are historically among the most heavily advertised drugs. In May 2010, Consumer Reports additionally reported that Nexium, one of the most widely-prescribed PPI’s, is also the most expensive. If your insurance does not cover it, it runs around $248 per month for a 20 mg dose. And for third party payors like self-funded employer insurance plans, the costs are truly staggering.
How many of the hundreds of thousands of people who began taking an acid-suppressing drug while in the hospital do you think would have been willing to take the drug — not to mention pay for it — if they had known that it could put them at risk for serious infections and was being prescribed to prevent a condition only 0.29% of hospital patients actually experience? Inundated as we are with direct-to-consumer advertising, we may sometimes need to stop and ask ourselves, are we really better informed?
 Herzig S., Howell M., Ngo, L. and Marcantonio, E., Acid-Suprressive Medication Use and the Risk for Hospital-Acquired Pneumonia, JAMA 2009; 301(2)): 2120.
 Gebhart, Fred, Routine use of acid-suppressive medication outside ICU questioned, Drug Topics, Vo. 155, Issue 4 (Apr. 15, 2011).
 Id. See also Less Is More When Prescribing Acid Suppressive Medications for Hospital Patients, available on the Beth Israel Deaconess Medical Center’s website, at http://www.bidmc.org/News/InResearch/2011/February/AcidSuppressives.aspx.
 Supra, n. 1 at 2127.
 Dial, S., Delaney, J., Barkun, A., Suissa, S., Use of Gastric Acid-Suppressive Agents and the Risk of Community-Acquired Clostridium difficile-Associated Disease, JAMA 2005; 294: 2989.
 Consumers Union Policy Brief: Hospital-Acquired C. Difficile Infections (CDI), November 2008.
 Consumer Reports, Drugs to treat heartburn, GERD, available at http://www.consumerreports.org/health/best-buy-drugs/heartburn_ppi.htm.
Photo Credit: Rennett Stowe