From the Guidelines
Patients discontinuing long-term proton pump inhibitor (PPI) therapy should be aware that they may experience transient upper GI symptoms due to rebound acid hypersecretion, a phenomenon where the stomach's acid-generating potential is unleashed after PPIs are stopped. This is because PPIs inhibit gastric acid production, leading to an increase in intragastric pH, which in turn causes serum gastrin levels to rise, promoting the proliferation of parietal cells and enterochromaffin-like cells, ultimately increasing the capacity of the stomach to produce acid 1. Key points to consider in managing hyperacidity on acid include:
- Rebound acid hypersecretion (RAHS) is a physiologic phenomenon that can occur with discontinuation of prolonged PPI therapy
- The increased parietal cell mass can cause a profound decline in gastric acidity, potentially leading to upper GI symptoms
- Patients should be advised of the potential for transient upper GI symptoms when discontinuing long-term PPI therapy, as stated in the AGA clinical practice update on de-prescribing of proton pump inhibitors: expert review 1. Some important considerations for managing hyperacidity include:
- Avoiding trigger foods (spicy, fatty, acidic)
- Eating smaller meals
- Maintaining upright posture after eating for 2-3 hours
- Limiting alcohol and caffeine
- Quitting smoking
- Managing stress It is essential to note that these lifestyle modifications are crucial in managing hyperacidity, and medications such as antacids, H2 blockers, or proton pump inhibitors may be necessary to provide relief from symptoms. However, the primary concern in this context is the potential for rebound acid hypersecretion after discontinuing PPI therapy, as highlighted in the 2022 study published in Gastroenterology 1.
From the FDA Drug Label
Serum concentrations necessary to inhibit 50% of stimulated gastric acid secretion are estimated to be 36 to 94 ng/mL. Following a single oral dose of 150 mg, serum concentrations of ranitidine are in this range up to 12 hours. Ranitidine inhibits both daytime and nocturnal basal gastric acid secretions as well as gastric acid secretion stimulated by food, betazole, and pentagastrin, It appears that basal-, nocturnal-, and betazole-stimulated secretions are most sensitive to inhibition by ranitidine, responding almost completely to doses of 100 mg or less, while pentagastrin- and food-stimulated secretions are more difficult to suppress.
The answer to Hyperacidity on acid is that Ranitidine can help inhibit gastric acid secretion.
- Key points:
- Ranitidine inhibits basal, nocturnal, and stimulated gastric acid secretions.
- Serum concentrations of 36 to 94 ng/mL are necessary to inhibit 50% of stimulated gastric acid secretion.
- A single oral dose of 150 mg maintains serum concentrations in this range for up to 12 hours.
- Basal and nocturnal secretions are more sensitive to inhibition by ranitidine than pentagastrin- and food-stimulated secretions. 2
From the Research
Hyperacidity on Acid
- Hyperacidity is a condition where the stomach produces excessive acid, which can lead to various symptoms and complications 3, 4, 5.
- The use of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) is common in the treatment of hyperacidity and related conditions such as gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD) 4, 5, 6, 7.
- PPIs and H2RAs work by reducing the production of stomach acid, but they can also have adverse effects, such as rebound hypersecretion of gastric acid after treatment, and tolerance development 3, 5, 7.
- Studies have shown that PPIs are generally more effective than H2RAs in healing ulcers and relieving symptoms, but H2RAs may be preferred in certain situations, such as in patients with mild symptoms or those who cannot tolerate PPIs 4, 5, 7.
- The long-term use of PPIs has been associated with an increased risk of adverse effects, such as diarrhea, constipation, headaches, and gastrointestinal infections, as well as an increased risk of fractures in older adults 5, 6, 7.
- In neonates and infants, the use of PPIs and H2RAs for GERD has been shown to have limited clinical benefit, and may be associated with an increased risk of adverse effects, such as allergies, anaphylactic reactions, and nosocomial infections 6.
- A comparison of PPIs and H2RAs for stress ulcer prophylaxis in the intensive care unit found that PPIs were associated with a higher 90-day mortality rate, but no significant difference in the risk of gastrointestinal bleeding 7.