Proton pump inhibitors in acute-on-chronic liver failure: a sheep in sheep's clothing

Proton pump inhibitors (PPIs) are one of the safest drugs available and are largely overprescribed in clinical practice. Preclinical studies have suggested that chronic use of PPIs may alter the gut microbiome and potentially promote gastrointestinal infections. Although the number to treat for a single infection event is high, the risk in patients with end-stage liver disease may be increased due to their inherent immunosuppression, altered gastroenteric barrier, and potential for bacterial translocation, resulting in spontaneous bacterial peritonitis. In the present issue of the Spanish Journal of Gastroenterology, García Gavilán et al. have published a prospective multicenter Andalusian study including 59 patients with acute-on-chronic liver failure (ACLF), among whom 26 patients were chronically exposed to PPIs. Patients with and without PPIs showed a comparable grade of ACLF, rate of complications, and mortality. The rates of infection and length of hospitalization were also evenly distributed in patients exposed and not exposed to PPIs. These results add to the existing evidence and discourage deprescription of PPIs in patients with ACLF if otherwise indicated.