Low-cost drug proves to be a win for patients and the health care system

As a critical care physician, Dr. Deborah Cook is committed to giving the best possible care to her patients in the intensive care unit (ICU) at St. Joseph's Healthcare in Hamilton.

That means making decisions based on the best available evidence as well as the patient's values, experience, and social context. As a steward of health care resources, Dr. Cook also takes into consideration the cost of tests, treatments, and procedures.

When Dr. Cook cares for a patient in the ICU who requires a breathing machine, she will usually prescribe an acid-lowering drug called pantoprazole to prevent stress erosions, a complication of critical illness in which ulcers develop in the lining of upper gastrointestinal system. Pantoprazole is a low-cost intervention. The drug costs between 50 cents and two dollars a dose.

Although rare, stress erosions can lead to serious bleeding. This complication may result in extra costs for hospitals by extending the time patients must spend in the expensive setting of the ICU and by increasing the need for additional tests and procedures.

While prescribing acid-lowering drugs had been common practice in ICUs around the world for decades, the evidence on the harms and benefits for patients was still unclear.

"With advances in clinical care practices as well as better drugs and devices, people wondered whether the bleeding from stress erosions had almost disappeared and whether pantoprazole was still effective," explains Dr. Cook, a Distinguished Professor of Medicine, Clinical Epidemiology & Biostatistics, and Academic Chair of Critical Care at McMaster University. "In fact, even though it's a low-cost drug, it was questioned whether it was really necessary to give it to most critically ill patients."

With funding from CIHR and partners, Dr. Cook and her team developed the Re-Evaluating the Inhibition of Stress Erosions (REVISE) trial, recruiting more than 4,800 patients in 68 ICUs in eight countries to determine the clinical effectiveness of pantoprazole in preventing gastrointestinal bleeding in patients on a breathing machine. The study included an economic evaluation led by Dr. Cook's colleague Dr. Feng Xie, a health economist and Professor in McMaster's Department of Health Research Methods, Evidence and Impact.

Some might wonder why an economic evaluation was needed on such a cheap drug.

"There's often a misunderstanding about economic evaluation and its value," says Dr. Xie. "An economic evaluation will not just look at the cost of intervention versus control, but also all the consequences associated with an intervention in terms of the health care resource use, such as the hospitalization, ICU stay procedures, and other medication use. So, we look at it from a hospital and health system level to try to understand the overall economic impact."

The team published the study in the New England Journal of Medicine in 2024. The results were definitive: patients who received pantoprazole had a significantly lower risk of gastrointestinal bleeding with no significant effect on complications or mortality. These findings have provided clear evidence about this prevention strategy which is influencing intensive care practice worldwide.

Through his economic evaluation, published in JAMA Network Open in 2025, Dr. Xie determined that patients who received pantoprazole spent an average of a day less in the ICU and fewer days in hospital overall, saving the health care system up to $5,000 per patient.

"The clinical trial work and the economic evaluation are a compelling combination," says Dr. Cook. "It's a win for patients and the health care system."