Can people be on Proton Pump Inhibitors (PPIs) long term?

Long-Term PPI Use: Evidence-Based Recommendations

Yes, people can and should remain on PPIs long-term when they have specific proven indications, including Barrett's esophagus, severe erosive esophagitis (LA grade C/D), or high-risk NSAID use requiring gastroprotection. 1, 2 However, patients without these definitive indications should be considered for de-prescribing after appropriate evaluation. 1

When Long-Term PPI Therapy Is Appropriate

The American Gastroenterological Association identifies clear indications where indefinite PPI therapy is warranted:

Definitive Indications for Lifelong Therapy:

• Barrett's esophagus - reduces esophageal adenocarcinoma risk 1, 2
• Severe erosive esophagitis (LA grade C or D) - prevents recurrence of mucosal damage 1, 3
• Gastroprotection in high-risk NSAID/aspirin users - prevents bleeding complications 1, 2
• Secondary prevention of gastric/duodenal ulcers - particularly in high-risk patients 1
• Esophageal strictures from GERD - maintains patency 1

Conditional Indications Requiring Ongoing Assessment:

• PPI-responsive endoscopy-negative reflux disease with symptom recurrence after discontinuation 1, 2
• Prevention of idiopathic pulmonary fibrosis progression 1

The 2022 AGA guidelines emphasize that patients with proven severe GERD phenotypes (LA grade C/D esophagitis, AET >12%, bipositional reflux, or DeMeester score >50) require either continuous long-term PPI therapy or anti-reflux procedures. 3

The Personalized Approach: Who Should NOT Be on Long-Term PPIs

Patients without proven GERD or erosive disease should attempt PPI discontinuation or dose reduction. 3, 2 The 2022 AGA guidelines provide a clear algorithm:

• No GERD on testing (normal endoscopy + AET <4% on all days of pH monitoring) → discontinue PPIs entirely 3
• Borderline GERD (LA grade A esophagitis or AET 4-6%) → wean to lowest effective dose or on-demand therapy with H2 blockers 3
• Non-erosive reflux disease responding to initial therapy → attempt step-down to on-demand therapy 3, 2

The critical distinction: on-demand therapy is reasonable for non-erosive disease but NOT for patients with a history of erosive esophagitis, where recurrence rates are unacceptably high. 3

Safety Profile: Addressing Concerns

The AGA explicitly recommends emphasizing the safety of PPIs for GERD treatment. 3 This recommendation is based on the fact that randomized controlled trials have not confirmed increased adverse events with long-term PPI use, despite observational associations suggesting risks. 1

What Monitoring Is NOT Needed:

• No routine screening of bone mineral density, serum creatinine, magnesium, or vitamin B12 2
• No routine supplementation beyond the Recommended Dietary Allowance for calcium, vitamin B12, or magnesium 2
• No routine probiotic use to prevent infection 2

This represents a significant departure from common clinical anxiety about PPI complications. The highest quality evidence does not support routine monitoring or prophylactic interventions. 2

Practical Management Strategy

Initial Assessment (4-8 weeks):

• Start FDA-approved single-dose PPI therapy 3
• Assess response at 4-8 weeks 3

For Responders Without Erosive Disease:

• Wean to lowest effective dose 3
• Consider on-demand therapy if symptoms remain controlled 3
• If chronic PPI needed at 1 year, perform reflux testing OFF PPI to determine appropriateness of lifelong therapy 3

For Patients With Proven Erosive Disease:

• Continue daily PPI indefinitely - do NOT attempt on-demand therapy 3
• Periodically reevaluate dose to ensure lowest effective dose 2
• Consider anti-reflux procedures for non-responders after appropriate physiologic testing 3

For Patients on Twice-Daily Dosing:

• Most should be stepped down to once-daily dosing unless they have severe GERD phenotype 1, 4

Critical Pitfall: Rebound Acid Hypersecretion

Warn patients that rebound acid hypersecretion is common after discontinuing long-term PPI therapy. 1, 4 This causes transient upper GI symptoms that may be mistaken for ongoing GERD, leading to unnecessary PPI resumption. Either dose tapering or abrupt discontinuation is acceptable when de-prescribing. 1

The De-Prescribing Decision

All patients without a definitive indication should be considered for trial de-prescribing. 1, 4 However, never discontinue PPIs in patients with:

• Complicated GERD (severe erosive esophagitis, esophageal ulcer, peptic stricture) 4
• Barrett's esophagus 4
• Eosinophilic esophagitis 4
• High risk for GI bleeding 4

The 2008 AGA position statement is clear: long-term PPI use is strongly recommended (Grade A evidence) for patients with esophagitis once proven clinically effective, titrated to the lowest effective dose. 3 Less than daily dosing as maintenance therapy is explicitly recommended against (Grade D) in patients who previously had erosive esophagitis. 3

Documentation and Ongoing Management

Regular indication review is mandatory for all patients on long-term PPIs. 1, 4 The primary care provider should document the ongoing indication at each visit. 4 This practice ensures appropriate use and identifies candidates for de-prescribing, balancing the proven benefits in appropriate patients against unnecessary exposure in those without clear indications.