Reasons to Decrease PPI Dose
All patients without a definitive indication for chronic PPI use should be considered for trial of de-prescribing, and most patients on twice-daily dosing should be considered for step down to once-daily PPI. 1
Primary Reasons for Decreasing PPI Dose
- After initial symptom control, PPI therapy should be titrated down to the lowest effective dose based on symptom control 1, 2
- Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step down to once-daily PPI 1
- Long-term use of PPIs at higher doses increases the risk of adverse effects, particularly osteoporosis-related fractures 3
- Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated 3
Potential Adverse Effects of Long-Term PPI Use
- Increased risk of bone fractures, particularly with high-dose and long-term therapy (a year or longer) 3, 4
- Risk of hypomagnesemia after prolonged use (typically at least three months, but most commonly after a year of therapy) 3
- Potential for vitamin B12 deficiency with long-term use (longer than three years) due to decreased absorption 3
- Increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients 3, 5
- Potential for acute tubulointerstitial nephritis 3
- Risk of cutaneous and systemic lupus erythematosus with continuous PPI therapy 3
Who Should Not Have Their PPI Dose Decreased
- Patients with complicated GERD, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture 1
- Patients with known Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis 1
- Patients at high risk for upper gastrointestinal bleeding 1
- Patients with Los Angeles grade C or D esophagitis require continuous daily maintenance therapy 2
Approach to Decreasing PPI Dose
- All patients taking a PPI should have a regular review of the ongoing indications for use and documentation of that indication 1
- When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered 1
- Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion 1
- For patients with non-erosive GERD who have responded to PPI therapy, on-demand therapy may be a reasonable alternative to continuous daily dosing 1
- PPI users should be assessed for upper gastrointestinal bleeding risk using an evidence-based strategy before de-prescribing 1
Special Considerations
- In patients undergoing intragastric balloon therapy for obesity, the lowest dose, frequency, and duration of PPIs should be used 1
- Patients with non-severe GERD often respond well to optimization of lifestyle and pharmacotherapy, and may ultimately be able to wean pharmacotherapy down to the lowest effective dose 1
- The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, not because of concern for PPI-associated adverse events 1
- Patients are willing to discuss the option of continuing PPI use or trying to reduce their PPI; however, a range of attitudes exist, making this a preference-sensitive decision 6
Monitoring After Dose Reduction
- Patients should be monitored for symptom recurrence after dose reduction 1
- For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), consider monitoring magnesium levels periodically 3
- Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines 3