Why would someone be on proton pump inhibitors (PPIs) chronically?

Indications for Chronic Proton Pump Inhibitor (PPI) Therapy

Chronic PPI therapy is definitely indicated for conditions with high risk of morbidity and mortality including Barrett's esophagus, severe erosive esophagitis (LA Classification grade C/D), gastroprotection in high-risk NSAID/aspirin users, and secondary prevention of peptic ulcers. 1

Definite Indications for Long-Term PPI Use (>8 weeks)

Long-term PPI therapy is appropriate in several specific clinical scenarios where the benefits clearly outweigh potential risks:

• Barrett's esophagus - Requires ongoing acid suppression to prevent progression to esophageal adenocarcinoma
• Clinically significant erosive esophagitis (LA Classification grade C/D) - Prevents recurrence of severe esophageal damage
• Gastroprotection in high-risk NSAID/aspirin users - Prevents potentially life-threatening GI bleeding
• Secondary prevention of gastric and duodenal peptic ulcers (without concomitant antiplatelet drugs) - Prevents recurrent ulceration and complications 1

Conditional Indications for Long-Term PPI Use

Some conditions may warrant chronic PPI therapy based on individual response and risk assessment:

• PPI-responsive endoscopy-negative reflux disease with recurrence upon PPI cessation - When symptoms consistently return after discontinuation
• Esophageal strictures from GERD (peptic strictures) - To prevent recurrent stricture formation
• Prevention of progression of idiopathic pulmonary fibrosis - In specific cases where benefit is demonstrated 1

Inappropriate Long-Term PPI Use

PPIs should not be continued chronically for:

• Nonerosive reflux disease with no sustained response to high-dose PPI therapy - Suggests alternative diagnosis
• Functional dyspepsia with no sustained PPI response - Other treatments more appropriate
• Empiric treatment of laryngopharyngeal symptoms - Lack of evidence for benefit 1, 2

Management Algorithm for Chronic PPI Use

1. Establish clear documentation of appropriate indication

   • Verify diagnosis with appropriate testing (endoscopy, pH monitoring)
   • Document ongoing need for therapy 1

2. For patients on chronic PPI therapy:

   • Attempt to use lowest effective dose
   • Consider step-down to once-daily dosing if currently on twice-daily regimen
   • Evaluate for potential de-prescribing at least annually 1

3. For patients with GERD on chronic PPI:

   • Consider reflux testing at 1-year timepoint to confirm need for lifelong therapy
   • If symptoms controlled, attempt to wean to lowest effective dose or on-demand therapy 1

Potential Risks of Chronic PPI Use

While PPIs are generally safe, long-term use has been associated with:

• Nutrient deficiencies - Vitamin B12, iron, magnesium, calcium
• Increased risk of infections - C. difficile, community-acquired pneumonia
• Potential kidney issues - Acute interstitial nephritis, chronic kidney disease
• Bone health concerns - Potential increased fracture risk
• Rebound acid hypersecretion - Upon discontinuation, leading to symptom recurrence and potential unnecessary continuation 2, 3, 4

Important Considerations for Clinicians

• Document indication clearly - Without an ongoing indication, PPIs only incur potential harm
• Regular reassessment - Review need for continued therapy at least annually
• Consider de-prescribing - For patients without definitive indication for chronic use
• Avoid double-dose regimens - Not FDA-approved and associated with higher complication rates 1
• Be aware of rebound hypersecretion - Inform patients that symptoms after discontinuation may represent rebound rather than disease recurrence 3

Pitfalls to Avoid

• Continuing PPI without documented indication - Leads to unnecessary exposure to potential adverse effects
• Failure to attempt dose reduction - Many patients can maintain symptom control on lower doses
• Not recognizing rebound acid hypersecretion - Can lead to inappropriate continuation of therapy
• Overlooking potential drug interactions - Particularly with clopidogrel and other medications 1, 4

Primary care providers should take primary responsibility for reviewing ongoing indications for PPI use and identifying candidates for de-prescribing, as they are typically the main prescribers of these medications 1.