From the Guidelines
PPIs are not entirely safe for long-term use, but they are essential for certain patients, such as those with a history of severe erosive esophagitis or GERD-related complications, and should be taken 30-60 minutes before food for optimal effectiveness. The use of PPIs has been shown to be effective in healing erosive esophagitis and preventing the development and recurrence of complications of GERD in long-term users 1. However, de-prescribing can be considered in patients without a history of severe erosive esophagitis or GERD-related complications, but PPI use should be quickly re-initiated in those who develop symptoms or signs suggestive of the emergence of complicated GERD 1. Some key points to consider when using PPIs include:
- Optimization of PPI includes ensuring adequate timing of dose, considering escalation to double dose, and/or switching to a different PPI 1
- Patients with erosive esophagitis (Los Angeles B or greater), biopsy-proven Barrett’s esophagus, and/or peptic stricture require at least single-dose, long-term PPI therapy 1
- Patients with severe GERD require indefinite long-term PPI therapy and/or an invasive anti-reflux procedure 1
- Long-term PPI use should be periodically reassessed due to potential risks including vitamin B12 deficiency, hypomagnesemia, increased fracture risk, and Clostridium difficile infections. It is essential to weigh the benefits and harms of PPI use and discuss them with the patient, especially in patients with a history of severe erosive esophagitis or GERD-related complications 1.
From the Research
Exceptions Regarding Proton Pump Inhibitors (PPIs)
- Not safe for long-term use: PPIs are associated with risks when used over an extended period 2.
- Timing of intake: The optimal time to take PPIs in relation to food is typically 30–60 minutes before eating, but this can vary depending on the specific medication and individual factors.
- Safety in pregnancy: There is evidence suggesting that PPIs can be safer in pregnancy compared to other acid-suppressing medications, but this should be determined on a case-by-case basis with medical supervision.
- Acid-blocking action compared to histamines: PPIs have a more potent and longer-lasting inhibition of gastric acid secretion compared to histamine-2-receptor antagonists, which may lose effectiveness due to tolerance 3.
Key Considerations
- PPIs are widely used for treating gastroesophageal reflux disease and other acid-related disorders, but their long-term use has been associated with increased risks 2, 4.
- The decision to continue or deprescribe PPIs should consider patient values and preferences, with an emphasis on symptom control and the potential for reducing or stopping PPI use 5.