What should I do for a patient taking a Proton Pump Inhibitor (PPI) and a Steroidal Anti-Inflammatory Drug (SAID) for an extended period with persistent symptoms?

Management of a Patient on Long-Term PPI and SAID with Persistent Symptoms

For a patient on long-term PPI and steroidal anti-inflammatory drug (SAID) therapy with persistent symptoms, you should evaluate the ongoing indication for PPI therapy, consider gastroprotection needs based on bleeding risk factors, and implement appropriate PPI deprescribing or optimization strategies.

Assessment of PPI Indication and Risk Factors

• Determine if there is a definitive ongoing indication for PPI therapy, such as Barrett's esophagus, severe erosive esophagitis, or gastroprotection for high-risk SAID users 1
• Assess for risk factors that warrant continued PPI therapy with SAID use, including:
  • Age over 60-65 years 1
  • History of upper GI bleeding 1
  • Concurrent use of anticoagulants or multiple antithrombotics 1
  • Concurrent use of aspirin or NSAIDs 1
  • Concurrent corticosteroid use 1
  • Presence of H. pylori infection 1

Management Algorithm Based on Risk Assessment

For High-Risk Patients (with definite indications):

• Continue PPI therapy if the patient has one or more risk factors for GI bleeding while on SAIDs 1
• Consider optimizing the PPI dose - step down from twice-daily to once-daily dosing if currently on higher doses 1
• Do not discontinue PPI solely based on concerns about potential PPI-associated adverse events 1

For Low-Risk Patients (without definite indications):

• Consider PPI deprescribing through either:
  • Gradual tapering (preferred approach) 2
  • Abrupt discontinuation 1
• Implement alternative symptom management strategies:
  • On-demand PPI use instead of continuous therapy 1
  • H2-receptor antagonists as needed 1
  • Over-the-counter antacids for breakthrough symptoms 1

Deprescribing Protocol

• Discuss with the patient the rationale for considering PPI reduction or discontinuation 3
• Explain that transient upper GI symptoms may occur due to rebound acid hypersecretion (RAHS) 1
• Advise that RAHS symptoms:
  • Do not necessarily indicate need for immediate return to continuous PPI therapy 1
  • Can typically be managed with on-demand therapy 1
  • Usually resolve within 2-6 months as parietal cell hyperplasia regresses 1
• Monitor for severe persistent symptoms lasting more than 2 months after discontinuation, which may suggest a continuing indication for PPI therapy 1

Important Considerations and Pitfalls

• Do not discontinue PPIs in patients with definite indications such as Barrett's esophagus or severe erosive esophagitis 1, 4
• Recognize that up to 50% of patients on long-term PPIs may not have an ongoing need for continuous therapy 3
• Be aware that patient concerns about PPI side effects may lead to self-discontinuation without medical guidance 1
• Document the indication for continued PPI use if therapy is maintained 1
• Understand that the evidence linking PPIs to adverse events comes primarily from observational studies with potential confounding factors 5
• Consider that tapering appears more effective than abrupt discontinuation for successful PPI withdrawal 2