Acid-suppressive medication use in acute stroke patients: is it time to change practice? Dear editor, Previous studies have shown that use of acid-suppressive medications may be associated with an increased risk of both community- and hospital-acquired pneu- monia (HAP) (1). Stroke patients are par- ticularly at high risk for HAP because of stroke-associated deficits such as somno- lence and dysphagia. Two studies from China reported an increased risk of HAP in stroke patients who were given proton- pump inhibitors (2) and histamine-2 receptor antagonists (3). Recently, Herzig et al. showed an increased risk for nosocomial pneumonia in hospitalized stroke patients who were treated with acid-suppressive medications (4). Signifi- cantly, after adjusting for 30 covariates, the odds ratio of HAP in the exposed group was 2·3 [95% confidence interval (CI) = 1·2–4·6]. The authors concluded that acid-suppressive medication use was associated with more than double the odds of HAP in patients presenting with acute stroke and recommended more restrictive use of these medications. At our institution, acid-suppressive medications are commonly used in hospitalized patients who present with acute stroke. After obtaining institutional review board approval, we reviewed 2357 patients who presented with acute stroke from November 1, 2012 to November 1, 2014. We excluded 382 patients for the following reasons: (1) acute stroke did not occur; (2) stroke occurred after hospital- ization; (3) pneumonia was present on admission; and (4) admissions < 48 h in duration. Among the remaining 1975 patients, there were 1335 acute ischemic stroke and 640 intracranial haemor- rhage (ICH). Acid-suppressive medica- tions were used in 1151 (58%). Only proton-pump inhibitors were used. Acid- suppressive medications were more likely to be used in patients with ICH than those with acute ischemic stroke (84% vs. 46%, P < 0·0001). There were 218 cases of HAP (11%) and 128 cases of community- acquired pneumonia (6·5%). The inci- dence of HAP was higher in those with ICH than those with acute ischemic stroke (17% vs. 8%, P < 0·0001). The odds ratio of developing HAP in patients who were given acid-suppressive medica- tions was 4·11 (95% CI = 2·84–5·95) for the entire cohort, 2·93 (95% CI = 1·91–4·47) for those with acute ischemic stroke, and 8·40 (95% CI = 2·61–27·00) for those with ICH. There were 16 cases of acute gastritis and 7 cases of gastrointes- tinal haemorrhage that were diag- nosed during the same hospitalization as the stroke episode. Acid-suppressive medications were used in all of these cases. In conclusion, we found an increased risk of HAP in patients with acute stroke, especially those with ICH. Future studies should include data on nasogastric or feeding tube usage, head of bed elevation, duration of treatment, oral vs. intrave- nous usage, dose of the medication used, clear documentation of the sequence of events, and a quantitative measure of the benefits conferred by acid-suppressive medication usage. We propose a double- blind randomized controlled trial to ascertain the impact of acid-suppressive medication use on the development of HAP. Zhi-li Wang 1 , Harrison X. Bai 2 , Xue Gao 3 , Dongxv Qiu 1 , and Li Yang 1 * 1 Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China 2 Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA 3 Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China References 1 Eom CS, Jeon CY, Lim JW et al. Use of acid- suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ 2011; 183:310–9. 2 Ran L, Khatibi NH, Qin X et al. Proton pump inhibitor prophylaxis increases the risk of nosocomial pneumonia in patients with an intracerebral hemorrhagic stroke. Acta Neurochir Suppl 2011; 111:435–9. 3 Sui R, Zhang L. Risk factors of stroke- associated pneumonia in Chinese patients. Neurol Res 2011; 33:508–13. 4 Herzig SJ, Doughty C, Lahoti S et al. Acid- suppressive medication use in acute stroke and hospital-acquired pneumonia. Ann Neurol 2014; 76:712–8. Correspondence: Li Yang*, Department of Neurology, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Road, Changsha, Hunan 410011, China. E-mail: yangli762@gmail.com Conflict of interest: None declared. Funding: This work was supported by the Natural Science Foundation of China (grant number 81301988) to Li Yang and China Ministry of Education Doctoral Program Spot Foundation (grant number 20130162120061) to Li Yang. DOI: 10.1111/ijs.12522 Letter to the editor © 2015 World Stroke Organization Vol 10, August 2015, E55 E55