What is the recommended protocol for tapering Proton Pump Inhibitors (PPIs) in patients on long-term therapy?

PPI Tapering Protocol for Patients on Long-term Therapy

When de-prescribing PPIs in patients on long-term therapy, either dose tapering or abrupt discontinuation can be considered, as both approaches are acceptable according to current guidelines. 1

Patient Selection for PPI Deprescribing

Before initiating any PPI tapering protocol, evaluate:

1. Ongoing indication assessment:

   • All patients taking PPIs should have regular review of ongoing indications 1
   • Primary care providers should be responsible for this review 1

2. Patients who should NOT be considered for PPI discontinuation:

   • Complicated GERD (severe erosive esophagitis, esophageal ulcer, peptic stricture) 1
   • Barrett's esophagus 1
   • Eosinophilic esophagitis 1
   • Idiopathic pulmonary fibrosis 1
   • High risk for upper gastrointestinal bleeding 1

3. Patients who SHOULD be considered for PPI discontinuation:

   • Those without a definitive indication for chronic PPI use 1
   • Patients on twice-daily dosing who could step down to once-daily 1, 2

Tapering Protocol Options

Option 1: Abrupt Discontinuation

• Completely stop PPI without tapering 1
• Suitable for patients without severe reflux disease
• Warn patients about potential rebound acid hypersecretion 1, 3

Option 2: Gradual Tapering

• Step 1: If on twice-daily dosing, first reduce to once-daily dosing for 2-4 weeks 2
• Step 2: Reduce standard dose to half-dose for 2-4 weeks
• Step 3: Switch to every-other-day dosing for 2 weeks
• Step 4: Complete discontinuation

Important Considerations During Tapering

1. Patient education:

   • Inform patients they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion 1, 3
   • Explain that rebound symptoms typically last 2-4 weeks

2. Monitoring during tapering:

   • Schedule follow-up at 4-8 weeks after initiating taper
   • Assess for symptom recurrence

3. Management of breakthrough symptoms:

   • Consider as-needed use of antacids or H2-blockers for mild symptoms
   • For alginate antacids for breakthrough symptoms 1
   • For nighttime symptoms, consider H2-receptor antagonists 1, 2

4. Factors affecting success of discontinuation:

   • GERD patients have more difficulty discontinuing PPIs than non-GERD patients 4
   • Higher baseline serum gastrin levels may predict difficulty in discontinuing 4

Special Considerations

1. Decision basis:

   • The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use 1
   • Do not discontinue solely due to concerns about PPI-associated adverse events 1

2. Success rates:

   • Approximately 27% of long-term PPI users can successfully discontinue therapy 4
   • Success rates are higher in non-GERD patients (48%) compared to GERD patients (21%) 4

3. Long-term monitoring after discontinuation:

   • Follow up at 6 months and 12 months to assess sustained discontinuation 5
   • Consider periodic reassessment of symptoms

By following this structured approach to PPI tapering, clinicians can help patients safely discontinue unnecessary long-term PPI therapy while minimizing rebound symptoms and maintaining quality of life.