When should Proton Pump Inhibitors (PPIs) be avoided in patients with Helicobacter pylori infection, peptic ulcer disease, osteoporosis, osteopenia, or dementia?

When to Avoid Proton Pump Inhibitors

PPIs should be avoided or discontinued when there is no proven indication, particularly in patients with unconfirmed GERD, and must be withheld for at least 7-14 days before H. pylori testing to prevent false-negative results. 1

Specific Clinical Scenarios Requiring PPI Avoidance or Discontinuation

During H. pylori Diagnostic Testing

• Withhold PPIs for at least 7-14 days (minimum 2 weeks preferred) before any H. pylori testing to avoid false-negative results on urea breath tests or stool antigen tests 1
• Antibiotics and bismuth must also be stopped for at least 4 weeks before testing 1
• This washout period is critical because PPIs temporarily suppress H. pylori without eradicating it, leading to unreliable test results 1

In Clostridioides difficile Infection (CDI)

• Discontinue PPIs in patients with suspected or confirmed CDI unless there is a compelling indication to continue 2
• While no randomized controlled trials have definitively proven that stopping PPIs reduces CDI risk, the clinical association between PPI use and CDI is well-established 2
• Stewardship activities to discontinue unneeded PPIs are strongly warranted in patients at high risk for CDI 2
• This recommendation prioritizes reducing CDI-related morbidity and mortality, even though the evidence level is not the highest 2

When No Proven Indication Exists

• Evaluate appropriateness and dosing within 12 months after PPI initiation if therapy was started for unproven GERD 3
• Strongly consider PPI discontinuation or de-escalation in patients whose symptoms are likely medication-related rather than GERD-related 3
• Do not assume neurologic symptoms (weakness, tingling, visual problems) are GERD manifestations—these are not typical extraesophageal GERD symptoms and suggest PPI-induced complications 3

In Patients with Long-Term Use and Risk Factors

• Exercise caution with long-term PPI use in patients with osteoporosis or osteopenia risk factors 4
• Predictive factors for low bone mineral density include age ≥50 years, menopause, calcium intake ≤550mg/day, and PPI use duration ≥30 months 4
• Use the lowest effective dose for patients with appropriate indications, as long-term PPI use is associated with osteopenia (52% of users) and osteoporosis (19% of users) 4

After Successful H. pylori Eradication in Uncomplicated Cases

• Do not continue prolonged PPI therapy after successful H. pylori eradication in uncomplicated duodenal ulcer patients 1
• Continue PPI only until eradication is confirmed in complicated duodenal ulcer or bleeding ulcer patients 1
• For gastric ulcers, continue PPI until complete healing is achieved and eradication is confirmed 1

Common Pitfalls to Avoid

Testing Too Soon After Treatment

• Never test for H. pylori eradication before 4 weeks post-treatment, as the gastric mucosa requires this recovery period 1
• In bleeding peptic ulcers specifically, delay testing to 4-8 weeks after the bleeding episode 1

Inappropriate Substitution During Active Treatment

• Do not replace urgent endoscopy with PPI administration in patients with active bleeding peptic ulcers—PPIs should not delay definitive endoscopic management 2
• High-dose PPI starting before endoscopy and continuing for 72 hours is reasonable but does not replace urgent endoscopy 2

Ignoring Drug Interactions and Complications

• Be aware that long-term PPI use carries risks including fractures, interaction with antiplatelet medications, chronic kidney disease, C. difficile infection, dementia, and deficiencies in magnesium, calcium, and vitamin B12 5
• These risks must be weighed against benefits, particularly in elderly or vulnerable populations 2

Algorithm for PPI Discontinuation Decision

1. Assess indication validity: Is there documented erosive disease, active peptic ulcer, or confirmed GERD? If no → discontinue 3
2. Evaluate H. pylori status: If testing needed → withhold PPI for 7-14 days 1
3. Check for CDI risk: If high risk or active CDI → discontinue unless compelling indication 2
4. Review duration and risk factors: If >30 months use + age ≥50 + low calcium intake → consider discontinuation or dose reduction 4
5. Confirm healing status: If uncomplicated DU with confirmed H. pylori eradication → discontinue 1