Why do we decrease Proton Pump Inhibitors (PPIs) over time?

From the Guidelines

Proton Pump Inhibitors (PPIs) should be decreased over time to minimize potential long-term side effects while maintaining symptom control, as recommended by the most recent guidelines 1. When treating conditions like GERD, peptic ulcers, or gastritis, the goal is to use the lowest effective dose for the shortest duration necessary.

Key Considerations

• After initial treatment (typically 4-8 weeks for GERD or 4-12 weeks for ulcers), patients should be stepped down to lower doses or less frequent dosing schedules.
• For example, transitioning from twice-daily to once-daily dosing, or from a standard dose (like omeprazole 20mg daily) to a lower maintenance dose (like 10mg daily).
• This tapering approach helps prevent rebound acid hypersecretion, which can occur with abrupt discontinuation and cause symptom recurrence, as noted in a recent study 1.

Potential Risks of Long-term PPI Use

• Long-term PPI use has been associated with potential risks including vitamin B12 and magnesium deficiencies, increased risk of bone fractures, Clostridium difficile infections, and kidney disease.
• For patients requiring ongoing therapy, periodic reassessment every 6-12 months is recommended to determine if continued treatment is necessary or if further dose reduction is possible, as suggested by the American Gastroenterological Association 1.

De-Prescribing Strategies

• When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered, with patients advised to be mindful of developing recurrent upper GI symptoms as a consequence of rebound acid hypersecretion 1.
• The use of on-demand PPIs, histamine type-2 receptor antagonists, or neutralizing antacids on an as-needed basis may be helpful for controlling symptoms in the short term without committing to continuous PPI therapy, as noted in a recent review 1.

From the FDA Drug Label

Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Avoid administration of PPIs for longer than medically indicated We decrease Proton Pump Inhibitors (PPIs) over time because:

• PPI therapy may be associated with an increased risk of several adverse events, including osteoporosis-related fractures, Clostridium difficile-associated diarrhea, and hypomagnesemia.
• Using the lowest dose and shortest duration of PPI therapy can help minimize these risks.
• Long-term PPI therapy (a year or longer) may lead to malabsorption of cyanocobalamin (vitamin B-12) and increase the risk of adverse events 2, 2.

From the Research

Reasons for Decreasing PPIs Over Time

• The long-term use of Proton Pump Inhibitors (PPIs) has been associated with adverse health outcomes, making it necessary to reduce or stop their use when possible 3.
• Studies have shown that prolonged acid suppression therapy with PPIs or H2 blockers may result in serum vitamin B12 deficiency, which can have serious health implications 4, 5.
• The definition of long-term PPI use varies, but it is generally considered to be more than 8 weeks in patients with reflux symptoms and more than 4 weeks in patients with dyspepsia or peptic ulcer 6.

Strategies for Reducing PPI Use

• Identifying patients who can reduce or stop PPI therapy without compromising symptom control is crucial 3.
• Strategies for reducing PPI use include gradual dose reduction, switching to alternative medications, or using non-pharmacological interventions 3.
• Monitoring vitamin B12 status and providing supplements if necessary can help mitigate the risks associated with long-term PPI use 4, 5.

Considerations for PPI Use

• The choice of PPI and its dosage should be individualized based on the patient's specific needs and medical history 7.
• Patients on long-term PPI therapy should be regularly assessed for potential adverse effects, such as vitamin B12 deficiency, and alternative treatments should be considered if necessary 4, 5.