How long should a patient be off Proton Pump Inhibitors (PPIs) before undergoing Helicobacter pylori (H. pylori) testing?

From the Guidelines

For accurate H. pylori testing, patients should stop taking proton pump inhibitors (PPIs) for at least 2 weeks before the test, as recommended by the Maastricht IV/Florence Consensus Report 1. This recommendation is based on the fact that PPIs can lead to false-negative results in H. pylori tests, such as urea breath tests, stool antigen tests, and endoscopic biopsies, due to the decrease in gastric acid production and subsequent reduction in bacterial load. Some key points to consider include:

• PPIs should be stopped for 2 weeks before testing by culture, histology, rapid urease test, UBT, or stool test, as stated in the consensus report 1.
• If it is not possible to stop PPIs, validated IgG serology can be performed, although this is a less preferred option with a lower grade of recommendation 1.
• The use of anti-H2 drugs may also lead to some false-negative results, but to a much lesser extent, and it is not necessary to stop them before testing if using citric acid 1.
• Stopping PPIs for 2 weeks allows the bacteria to repopulate the stomach, making the tests previously negative once again positive 1.

From the Research

H pylori Testing and PPI Use

• The use of proton pump inhibitors (PPIs) can lead to false-negative results in Helicobacter pylori diagnostic tests, including biopsy culture and rapid urease test (RUT) 2.
• Studies have shown that PPI consumption can inhibit the growth of H. pylori and reduce the sensitivity of diagnostic tests 2, 3.
• The duration of PPI use before testing can affect the accuracy of the results, with longer use leading to a higher likelihood of false-negative results 4.

Recommended Time Off PPI Before Testing

• One study suggests that cessation of PPI consumption at least 12 days before endoscopy could help avoid false-negative results of H. pylori diagnostic tests 2.
• Another study recommends stopping PPI use 2 weeks before testing to improve the reliability of H. pylori diagnostic tests 5, 4.
• The urea breath test results can revert to positive after completion of PPI therapy, with 91% of patients having positive results at 3 days, 97% at 7 days, and 100% at 14 days after stopping PPI use 4.

Alternative Testing Methods

• Stool antigen testing (SAT) may be less likely to yield false-negative results compared to other tests, particularly when domestically produced kits are used 6.
• SAT using a bioluminescent enzyme immunoassay is recommended due to its high sensitivity, even during PPI use 6.