From the Guidelines
Patients with paraesophageal hernias should not automatically be placed on permanent proton pump inhibitor (PPI) therapy, and the decision to use long-term PPI therapy should be individualized based on the presence and severity of symptoms such as heartburn, regurgitation, or chest pain. For symptomatic patients, PPIs like omeprazole (20-40mg daily), pantoprazole (40mg daily), or esomeprazole (20-40mg daily) may be appropriate, as suggested by the AGA clinical practice update on the personalized approach to the evaluation and management of GERD 1. However, asymptomatic patients with incidentally discovered paraesophageal hernias generally do not require PPI therapy. If surgery is planned, PPIs are typically continued until the hernia is repaired. For patients managing symptoms medically, lifestyle modifications should accompany PPI use, including:
- Avoiding large meals
- Not eating within 3 hours of bedtime
- Elevating the head of the bed
- Avoiding trigger foods Long-term PPI use carries potential risks including vitamin B12 deficiency, hypomagnesemia, increased risk of certain infections, and bone density concerns, so the benefits must outweigh these risks, as highlighted in the AGA clinical practice update on de-prescribing of proton pump inhibitors 1. Regular reassessment of symptoms and the continued need for PPI therapy is recommended rather than assuming lifelong treatment is necessary for all patients with paraesophageal hernias. The American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease also supports the use of continuous PPI therapy to maintain a healed mucosa and reduce the risk of recurrent heartburn, but notes that discontinuing therapy will likely result in recurrent heartburn 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Management with PPI
- Patients with a paraesophageal hernia may experience symptoms of gastroesophageal reflux disease (GERD) that can be managed with proton pump inhibitors (PPIs) 2, 3, 4, 5, 6.
- The use of PPIs has been shown to be effective in healing erosive esophagitis and preventing recurrence 2, 5.
- However, the long-term use of PPIs may mask symptoms of hiatal hernia recurrence, potentially delaying proper diagnosis and treatment 4.
PPI Use After Hiatal Hernia Repair
- A study found that 70% of patients remained or were restarted on PPI after their initial surgery, which may delay proper workup to identify recurrent hiatal hernia 4.
- The use of PPIs in patients who have undergone hiatal hernia repair should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms 4.