We have read the comments by Salvador and Rivera1 on the recommendations by Valdovinos-García et al. (2025), regarding the prescription and deprescription of proton pump inhibitors (PPIs),2 with great interest, in particular, the therapeutic algorithm proposed for PPI use in the intensive care unit (ICU). After reviewing the algorithm with the published recommendations, we believe it reflects the indications of the original consensus, especially with respect to the clinical conditions and risk factors that justify prophylaxis with PPIs in the ICU. According to our consensus, “PPI use as a prophylactic measure is recommended in patients admitted to the intensive care unit with risk factors for stress ulcers” which lays the groundwork for restricting PPI use in intensive care, limiting their use to only high-risk cases. The algorithm presented by Salvador and Rivera correctly incorporates the main risk factors described in the consensus: prolonged mechanical ventilation (more than 48 h) and the presence of coagulopathy. Those 2 factors have been identified by experts as the most important for precipitating gastrointestinal bleeding due to stress ulcers in critically ill patients, with estimated relative risks of 15.6 for ventilation > 48 h and 4.3 for coagulopathy. In this sense, the algorithm is in line with the original recommendations, by requiring the presence of mechanical ventilation > 48 h or coagulopathy for indicating PPIs in the ICU.3 Notably, the original article reports that clinically significant gastrointestinal bleeding in the ICU occurs in ∼1% of critically ill patients without prophylaxis, but despite its low frequency, is an important cause of death. Precisely for that reason, prophylaxis with PPIs is indicated in high-risk patients in the ICU because it can reduce the incidence of bleeding by around 60%. If the abovementioned algorithm considers additional factors (e.g., other comorbidities or situations of extreme physiologic stress in the ICU), it should be clarified that the original article does not mention them explicitly as primary indications for prophylaxis. The consensus authors focused their recommendation on the 2 factors with the most solid statistical support (prolonged mechanical ventilation and coagulopathy). This does not exclude other clinical contexts that increase the risk of bleeding (such as septic shock, severe burns, brain trauma, high-dose corticosteroid use, etc.),3–5 but instead, indicates that the available evidence confers special importance upon prolonged ventilation and coagulopathy. In practice, those other factors tend to be considered relevant when they accumulate or are added to the major ones. The consensus did not list them, perhaps in an effort to prioritize conciseness and higher quality evidence. At any rate, the nucleus of the algorithm –to restrict PPI prescription in the ICU to patients at a significant risk for bleeding– concurs with the spirit of the original recommendations.

In addition, we wish to reinforce the validity of the algorithm regarding PPI deprescription, once the patient is no longer exposed to risk factors in the ICU. In the recommendations, we clearly state that there is no significant difference between different PPI doses or administration routes for purposes of prophylaxis, for which the standard dose is recommended and the treatment maintained, only while the patient presents with risk factors, suspending it once the risk factors are resolved. This indication is fundamental for preventing unnecessarily prolonged treatments with PPIs in the critically ill patient. In fact, the consensus authors emphasize the fact that PPIs are among the most overused drugs: up to two-thirds of the patients that take them lack an appropriate indication for their chronic use. Therefore, suspending the PPI in the absence of a clear indication (such as prophylaxis in a patient no longer intubated or coagulopathic) is considered good clinical practice.

In conclusion, the therapeutic algorithm proposed by Salvador and Rivera for PPI use in patients in the ICU is consistent with the recommendations by Valdovinos-García et al. (2025). Said algorithm adequately reflects the recommendation that the indication for prophylaxis with PPIs should be limited to critically ill patients at a confirmed high risk (mainly mechanical ventilation > 48 h or coagulopathy) and coincides with the original consensus in discouraging PPI use when there are no such risk factors. That congruence, supported by data in the original article, strengthens the validity of the algorithm and contributes clarity in the practical application of the recommendations, emphasizing the judicious use of PPIs in the ICU, as well as their timely deprescription, once the conditions of risk are overcome.