PPI Tapering for Resolved GERD Symptoms
Most patients with resolved GERD symptoms should be tapered off proton pump inhibitors (PPIs) to the lowest effective dose or discontinued completely, unless they have a definitive indication for chronic PPI therapy. 1
When to Taper PPIs
Candidates for PPI Discontinuation:
- Patients with non-erosive reflux disease (NERD) whose symptoms have resolved 1
- Patients without a definitive indication for chronic PPI use 1
- Patients on twice-daily dosing who can be stepped down to once-daily PPI 1
- Patients with resolved symptoms who have been on PPI therapy for more than 8 weeks without an ongoing indication 1
Not Candidates for PPI Discontinuation:
- Patients with complicated GERD, such as severe erosive esophagitis (LA Classification grade C/D) 1
- Patients with Barrett's esophagus 1
- Patients with history of esophageal ulcer or peptic stricture 1
- Patients with long-segment (≥3cm) Barrett's esophagus 1
How to Taper PPIs
Recommended Tapering Approach:
- First, step down from twice-daily to once-daily dosing if applicable 1
- Then, taper to the lowest effective dose that controls symptoms 1
- Consider conversion to on-demand therapy for patients who can successfully wean 1, 2
- For patients requiring long-term therapy (>12 months), consider objective testing to confirm the need for continued therapy 1
Monitoring During Tapering:
- Assess for symptom recurrence during the tapering process 1
- If symptoms recur, return to the previous effective dose 1
- For patients with persistent need for PPI therapy, document the ongoing indication clearly 1
Benefits of PPI Tapering
- Reduces medication burden and associated costs 1
- Minimizes potential adverse effects related to long-term use 1
- On-demand therapy can reduce daily PPI use by approximately 50% compared to continuous therapy in appropriate patients 2
- Decreases risk of potential complications associated with higher-dose PPIs (community-acquired pneumonia, hip fracture, C. difficile infection) 1
Factors That May Predict Poor Response to PPI Discontinuation
- Body mass index < 23 kg/m² 3
- Sleep dysfunction 3
- History of psychotherapy or neuropsychiatric medication 3
- Non-erosive reflux disease (NERD) 3
Special Considerations
- Patients with PPI-responsive endoscopy-negative reflux disease who experience symptom recurrence upon PPI cessation may be conditionally indicated for long-term use 1
- For patients requiring chronic PPI therapy, evaluate the appropriateness and dosing within 12 months after initiation 1
- Consider endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriate use of long-term PPI therapy in patients with unproven GERD 1
Implementation Strategy
- Primary care providers should be primarily responsible for reviewing ongoing indications for PPI use and identifying candidates for de-prescribing 1
- Develop a care plan for long-term management, including possible de-escalation, in a shared decision-making model with the patient 1
- Provide patient education on GERD mechanisms, lifestyle modifications, and dietary behaviors that may help control symptoms during and after tapering 1