Why are Proton Pump Inhibitors (PPIs) given?

From the Guidelines

Proton pump inhibitors (PPIs) are given to reduce stomach acid production and are primarily prescribed to treat conditions caused by excess stomach acid, including gastroesophageal reflux disease (GERD), peptic ulcers, erosive esophagitis, and Zollinger-Ellison syndrome, as indicated in the 2022 AGA clinical practice update on de-prescribing of proton pump inhibitors 1. The main indications for PPI use can be summarized as follows:

• Definitely indicated for long-term use: Barrett’s esophagus, clinically significant erosive esophagitis, gastroprotection in users of ASA/nonsteroidal anti-inflammatory drug at high risk for GI bleeding, and secondary prevention of gastric and duodenal peptic ulcers with no concomitant antiplatelet drugs.
• Definitely indicated for acute/short-term use: Helicobacter pylori eradication, eosinophilic esophagitis, treatment of NSAID-related gastric and duodenal peptic ulcers, and ulcer prevention after sclerotherapy or band ligation treatment of esophageal varices. PPIs work by irreversibly binding to and inhibiting the hydrogen-potassium ATPase enzyme system (the "proton pump") in the gastric parietal cells, which is responsible for the final step in acid production. Some key points to consider when prescribing PPIs include:
• Typical dosing ranges from 20-40mg daily for most PPIs, with treatment duration varying based on the condition being treated—from 4-8 weeks for uncomplicated GERD to long-term use for severe erosive esophagitis or Barrett’s esophagus.
• PPIs are most effective when taken 30-60 minutes before the first meal of the day, as they work best when the acid-producing cells are most active.
• While generally safe for short-term use, long-term PPI therapy may be associated with potential risks including vitamin B12 and magnesium deficiencies, increased risk of bone fractures, and rarely, kidney problems. In patients on various types of antithrombotic therapy, proton pump inhibitors may be effective in reducing the risk of GI bleeding, in particular from gastroduodenal lesions, as recommended in the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Additionally, PPI therapy should be given two times per day for at least 8–12 weeks prior to assessment of histological response while on treatment, as recommended in the 2022 British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults 1.

From the FDA Drug Label

A prescription medicine called a proton pump inhibitor (PPI) used to reduce the amount of acid in your stomach. In adults, pantoprazole sodium delayed-release tablets are used for:

• up to 8 weeks for the healing and symptom relief of acid-related damage to the lining of the esophagus (called erosive esophagitis or EE)
• maintaining healing of EE and to help prevent the return of heartburn symptoms caused by GERD.
• the long-term treatment of conditions where your stomach makes too much acid.

Proton Pump Inhibitors (PPIs), such as omeprazole and pantoprazole, are given to reduce the amount of acid in the stomach. They are used for various purposes, including:

• Healing and symptom relief of acid-related damage to the esophagus (erosive esophagitis)
• Maintaining healing of EE and preventing the return of heartburn symptoms caused by GERD
• Long-term treatment of conditions where the stomach makes too much acid, such as Zollinger-Ellison Syndrome 2

From the Research

Reasons for Giving Proton Pump Inhibitors (PPIs)

• PPIs are given to patients with acid-related disorders, such as gastroesophageal reflux disease (GERD) and peptic ulcer disease, as they are the most potent gastric acid-suppressing agents in clinical use 3.
• The efficacy of PPIs is improved over histamine H2 receptor antagonists and other drugs in healing duodenal and gastric ulcers 3.
• PPIs are used to eradicate Helicobacter pylori in patients with H. pylori-positive duodenal ulceration, in combination with 2 antibacterials, which can eradicate H. pylori in over 90% of cases and significantly reduce ulcer recurrence 3.
• PPIs have efficacy advantages over ranitidine and misoprostol and are better tolerated than misoprostol in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) 3.
• PPIs are used to treat severe reflux, with ulceration and/or stricture formation, and have become the treatment of choice for the management of gastric acid hypersecretion in Zollinger-Ellison syndrome 3.

Specific Indications for PPI Use

• Stress ulcer prophylaxis in hospitalized patients 4.
• Peptic ulcer bleeding in hospitalized patients 4.
• Erosive esophagitis and peptic ulcer disease in patients with short bowel syndrome 5.
• Ulcer prophylaxis in patients undergoing intestinal transplantation 5.

Comparison of Oral versus Intravenous PPIs

• High dose oral PPI can be a good alternative to high dose IV PPI in patients with bleeding peptic ulcer who are at high risk of re-bleeding 6.
• There were no significant statistical differences between the two groups in the volume of blood transfusion, mean duration of hospital stay, need to surgery, or mortality rates 6.