Long-term PPI therapy: ‘Deprescribe’ or continue at lowest effective dose, expert advises
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According to one expert at Guild 2022, physicians should “re-ground” their approach to long-term proton pump inhibitor use and consider data-driven recommendations about its indications, known benefits and risks.
“There is a firehose of information about proton pump inhibitors — not for only for us but also for our patients,” Doug A. Corley, MD, PhD, research scientist at Kaiser Permanente of Northern California and clinical professor of medicine at University of California, San Francisco, said during the presentation.
When reviewing indications for long-term PPI therapy, Corley recommends deprescribing, if the indication and duration for use is inappropriate. However, with appropriate indication, PPIs should be continued at the lowest effective dose. Physicians should also have a discussion with their patients about reducing the frequency of or discontinuing PPI use if treatment is successful.
“PPIs work well for a lot of disorders,” Corley said. “However, not everyone with [gastroesophageal reflux disease (GERD)] needs them.”
Corley noted that with PPIs, the absolute risk for most patients is low and outweighed by proven benefits. In addition, most reported side effects are later debunked and may be related to B12, infection or iron.
Among recommendations for PPI use are:
absolute indications, such as esophagitis and ulcer prophylaxis
lifestyle and H2 receptor antagonists for mild-to-moderate GERD
once daily dosing for initiation and for most maintenance
8-week trial for GERD
try a lower dose (if on twice daily) and as needed dosing
review periodically if patients continue to use
Perspective
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Claire Beveridge, MD
PPI use and de-escalation are important topics. Indications for PPI use can include GERD (erosive and non-erosive), peptic ulcer disease (PUD), treatment of H. pylori, Barrett’s esophagus and eosinophilic esophagitis. While there is more reassurance in using PPIs after the large, randomized controlled trial by Moayyedi and colleagues, it is nonetheless necessary to exercise prudence when prescribing any medication. It is important to recognize which patients can stop PPI therapy: Examples include a patient with an H. pylori-associated gastric ulcer who has been successfully treated or a ventilated patient placed on PPI for PUD prophylaxis who has recovered and is being discharged from the hospital. On the other hand, there are patients who need long-term therapy, and for these patients, finding the lowest effective dose is key. When helping a patient lower their PPI dose, assessing consistent use and proper timing around mealtimes is important.
Moayyedi P, et al. Gastroenterology. 2019;doi:10.1053/j.gastro.2019.05.056.
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Corley DA. Proton Pump Inhibitors: When and why to use and when to stop. Presented at: GUILD 2022; Feb. 20-23, 2022 (hybrid meeting).
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