Can Proton Pump Inhibitors (PPIs) be used at less frequent doses than once daily?

Using PPIs at Less Frequent Doses Than Once Daily

Yes, PPIs can be used at less frequent doses than once daily for certain conditions, particularly for on-demand therapy in patients with non-erosive reflux disease where symptom control is the primary objective. 1

Appropriate Candidates for Less Frequent PPI Dosing

• Patients with symptomatic esophageal syndrome without esophagitis can effectively use PPIs on an as-needed basis when symptom control is the primary objective 1
• Patients with endoscopy-negative reflux disease may benefit from initial or on-demand treatment rather than daily maintenance therapy 1
• Patients without a definitive indication for chronic PPI use should be considered for de-prescribing or reduced dosing schedules 1

Inappropriate Candidates for Less Frequent PPI Dosing

• Patients with a history of erosive esophagitis should not use less than daily dosing of PPI therapy as maintenance therapy 1
• Patients with complicated GERD (severe erosive esophagitis, esophageal ulcer, peptic stricture) should generally not be considered for PPI discontinuation or reduced dosing 1
• Patients with Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should maintain their prescribed PPI regimen 1
• Patients at high risk for upper gastrointestinal bleeding who require gastroprotection 1

Dosing Considerations

• For short-term therapy, PPIs are more effective than histamine receptor antagonists (HRAs), which are more effective than placebo 1
• On-demand therapy is a reasonable strategy in patients with an esophageal GERD syndrome without esophagitis 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

Clinical Approach to PPI Dosing

1. Review indication for PPI use:

   • All patients taking a PPI should have a regular review of the ongoing indications for use 1
   • Document the indication and determine if it's still appropriate 1

2. Consider step-down therapy:

   • Patients on twice-daily dosing should be considered for step down to once-daily PPI 1
   • The lowest effective PPI dose should be prescribed to manage the condition 2

3. For non-erosive disease:

   • On-demand therapy can be considered instead of daily maintenance 1
   • This approach reduces pill burden and potential long-term risks 3

Important Caveats

• Double-dose PPIs (standard dose twice daily or double-strength once daily) have not been studied in randomized controlled trials and are not FDA-approved 1
• Higher-dose PPIs increase costs and have been more strongly associated with certain complications, including community-acquired pneumonia, hip fracture, and Clostridium difficile infection 1
• Patients with GERD and acid-related complications should take a PPI for short-term healing, maintenance of healing, and long-term symptom control 2
• The decision to discontinue or reduce PPI dosing should be based on lack of indication, not because of concern for potential adverse events 1

Pitfalls to Avoid

• Discontinuing PPIs in patients with strong indications for use may lead to symptom recurrence and complications 1
• Using less than daily dosing in patients with a history of erosive esophagitis can lead to high rates of disease recurrence 1
• Overuse of PPIs, especially chronic treatment at high doses, increases the risk of side effects and healthcare expenditures 3
• Failure to recognize rebound acid hypersecretion when reducing PPI dosing may lead to premature resumption of full-dose therapy 1