Duration of PPI Therapy for Barrett's Esophagus
Patients with Barrett's esophagus should remain on long-term PPI therapy indefinitely and should not be considered for PPI discontinuation. 1, 2
Definitive Indication for Lifelong Therapy
Barrett's esophagus is explicitly classified as a "definitely indicated for long-term use (>8 weeks)" condition for PPI therapy according to the 2022 AGA guidelines. 1 This is one of the few absolute indications where chronic PPI therapy should not be discontinued, regardless of symptom status. 1, 2
The rationale for indefinite therapy includes:
Reduction in dysplasia and cancer risk: PPI therapy reduces the risk of progression to esophageal adenocarcinoma. 2, 3, 4 Patients who delayed PPI initiation for 2+ years after Barrett's diagnosis had 5.6 times the risk of developing low-grade dysplasia and 20.9 times the risk of high-grade dysplasia or adenocarcinoma compared to those starting PPIs within the first year. 3
High nocturnal acid exposure: Patients with Barrett's esophagus, particularly those with long-segment disease (>3 cm), have markedly elevated nocturnal esophageal acid exposure that requires ongoing suppression. 1, 2
Effective symptom control and esophagitis healing: PPIs effectively heal and prevent relapse of erosive esophagitis commonly associated with Barrett's esophagus. 1, 2
Dosing Strategy
Start with once-daily PPI therapy for most patients with Barrett's esophagus. 5 Approximately 78% of Barrett's patients achieve adequate acid suppression with once-daily dosing. 5
Consider twice-daily PPI dosing for patients who: 1, 2
- Do not respond clinically to once-daily therapy
- Have long-segment Barrett's esophagus (>3 cm circumferentially) with particularly high nocturnal acid exposure 1, 2
- Demonstrate persistent abnormal acid exposure on pH monitoring despite once-daily therapy 1
However, there is no evidence supporting routine double-dose therapy for all Barrett's patients. 1 The decision to escalate should be individualized based on symptom response and, when available, objective pH monitoring data. 1
Critical Caveats
Do not attempt PPI de-prescribing or step-down therapy in Barrett's esophagus patients, even if asymptomatic. 1, 2, 6 This distinguishes Barrett's from uncomplicated GERD, where dose reduction may be appropriate. 1
Asymptomatic Barrett's patients should also continue long-term PPIs. 6 The protective effect against neoplastic progression exists independent of symptom control. 3, 4
Surveillance endoscopy remains mandatory despite PPI therapy, as some patients may still have abnormal acid exposure even without symptoms. 1, 2 PPIs reduce but do not eliminate cancer risk. 2
Antireflux surgery is not superior to medical therapy for preventing dysplasia or cancer progression in Barrett's esophagus and should only be considered for PPI-intolerant patients. 2
Common Pitfall to Avoid
The most significant error is treating Barrett's esophagus like uncomplicated GERD and attempting PPI discontinuation or on-demand therapy. 1, 7 On-demand therapy is explicitly inappropriate for Barrett's esophagus, where continuous maintenance PPI therapy may reduce dysplasia incidence. 7 Barrett's esophagus requires lifelong daily PPI therapy, not intermittent or on-demand use. 1, 2, 6