From the Guidelines
Discontinuing Proton Pump Inhibitors (PPIs) can lead to transient upper GI symptoms due to rebound acid hypersecretion (RAHS).
Side Effects of Discontinuing PPIs
- Patients who discontinue long-term PPI therapy may develop transient upper GI symptoms, such as heartburn, regurgitation, and dyspepsia, due to RAHS 1.
- RAHS is a physiologic phenomenon that occurs when PPIs are discontinued, leading to an increase in gastric acid production and a decrease in intragastric pH.
- The anticipated duration of RAHS after PPI withdrawal is not well characterized, but it is thought to last for several weeks to months, with enterochromaffin-like cells and parietal cell mass usually regressing by 6 months after withdrawal 1.
Management of Side Effects
- Patients who discontinue PPIs should be advised to be mindful of developing recurrent upper GI symptoms and to manage them with lower-potency options, such as histamine type-2 receptor antagonists or neutralizing antacids, on an as-needed basis 1.
- Dose tapering or abrupt discontinuation of PPIs can be considered, with no significant difference in the likelihood of remaining off PPIs and symptom-free at 6 months 1.
- Severe persistent symptoms lasting more than 2 months after PPI discontinuation may suggest the presence of a continuing indication for PPI therapy on a non-acid-mediated cause of symptoms 1.
From the Research
Side Effects of Discontinuing Proton Pump Inhibitors (PPIs)
The side effects of discontinuing PPIs are mainly related to rebound acid hypersecretion due to secondary hypergastrinaemia, which can lead to increased risk of gastrointestinal infections 2.
- Rebound acid hypersecretion: This occurs when the body produces more acid than normal after stopping PPI treatment, leading to symptoms such as heartburn and acid reflux 2, 3.
- Gastrointestinal infections: The increased risk of gastrointestinal infections is a potential side effect of long-term PPI use and discontinuation 2.
- Recurrence of symptoms: Abrupt discontinuation of PPIs can cause symptoms to recur, making it challenging to discontinue treatment successfully 4.
Strategies for Discontinuation
To minimize the side effects of discontinuing PPIs, several strategies can be employed, including:
- Tapering the PPI dose: Gradually reducing the PPI dose can help avoid rebound symptoms and increase the chances of successful discontinuation 4, 3.
- Step-down approach: Using alternative medications, such as histamine-2 receptor antagonists, can help manage symptoms after PPI discontinuation 3.
- On-demand therapy: Allowing patients to take intermittent PPI courses can reduce overall use and cost while preserving patient satisfaction 3.
Outcomes of Discontinuation
Studies have shown that discontinuation of PPIs can be successful in many patients, with one study finding that 70% of residents who discontinued PPI therapy remained asymptomatic after 8 weeks 5. However, further research is needed to determine the best approaches to PPI discontinuation, particularly in older populations 5.