What are the recommendations for chronic Proton Pump Inhibitor (PPI) use?

Recommendations for Chronic Proton Pump Inhibitor (PPI) Use

All patients on chronic PPI therapy should have regular review of ongoing indications, with discontinuation considered for those without definitive indications for long-term use. 1

Appropriate Indications for Long-Term PPI Use

Long-term PPI therapy (>8 weeks) is definitely indicated for:

• Barrett's esophagus
• Clinically significant (LA Classification grade C/D) erosive esophagitis
• Gastroprotection in high-risk users of ASA/NSAIDs
• Secondary prevention of gastric and duodenal peptic ulcers 1

Conditionally indicated for long-term use:

• PPI-responsive endoscopy-negative reflux disease with recurrence upon PPI cessation
• Esophageal strictures from GERD (peptic strictures) 1

Inappropriate Long-Term PPI Use

PPIs are not indicated for long-term use in:

• Symptoms of nonerosive reflux disease with no sustained response to high-dose PPI therapy
• Empiric treatment of laryngopharyngeal symptoms
• Acute undifferentiated abdominal pain 1

De-prescribing Algorithm

1. Assess indication: Review and document the original indication for PPI use 1
2. Evaluate necessity:
   • If patient has a definitive indication (see above), continue therapy
   • If no definitive indication exists, consider de-prescribing 1
3. Dose optimization:
   • For patients requiring chronic therapy, consider stepping down from twice-daily to once-daily dosing 1
   • Use the lowest effective dose that controls symptoms 2

Special Considerations

Patients with GERD

• Patients with complicated GERD (severe erosive esophagitis, esophageal ulcer, peptic stricture) should generally not be considered for PPI discontinuation 1
• For uncomplicated GERD, consider on-demand therapy (taking PPI only when symptoms occur) 2

Patients on NSAIDs/Aspirin

• PPI therapy is appropriate for patients with previous GI events who are on aspirin 1
• For patients ≥65 years with previous complicated GI events on aspirin, steroids, or warfarin, PPI therapy is appropriate 1

Risk Considerations

Long-term PPI use carries potential risks:

• Clostridium difficile infection: PPIs may increase risk, especially in hospitalized patients 1, 3, 4
• Bone fracture: Associated with high-dose, long-term therapy 3, 4
• Acute tubulointerstitial nephritis: Can occur at any point during therapy 3, 4
• Vitamin B12 deficiency: May occur after prolonged use (>3 years) 3, 4
• Hypomagnesemia: Rare but reported after prolonged use 3, 4
• Cutaneous and systemic lupus erythematosus: Reported as both new onset and exacerbation 3, 4

Practical Implementation

• Regular review: Primary care providers should regularly review PPI indications 1
• Documentation: Clearly document the indication and ongoing need 1
• Monitoring: For patients on long-term therapy, consider monitoring for:
  • Magnesium levels, especially if on other medications that may cause hypomagnesemia 4
  • Vitamin B12 levels for those on therapy >3 years 3, 4
  • Bone density for those at risk of osteoporosis 3, 4

Common Pitfalls to Avoid

1. Continuing PPIs indefinitely without reassessment: All patients on PPIs should have regular review of ongoing indications 1
2. Using twice-daily dosing when once-daily is sufficient: Most patients can be managed with once-daily dosing 1
3. Discontinuing PPIs in patients with definitive indications: This may lead to serious complications in patients with conditions like severe erosive esophagitis 1
4. Ignoring potential drug interactions: PPIs may interact with medications like clopidogrel 5
5. Overlooking monitoring needs: Patients on long-term therapy should be monitored for potential deficiencies and adverse effects 3, 4

By following these evidence-based recommendations, clinicians can optimize PPI therapy, minimizing risks while ensuring appropriate treatment for patients who truly need these medications.