PPI Tapering Strategy with Alternating Dexlansoprazole and Famotidine
Alternating dexlansoprazole 30 mg every other day with famotidine on off-days is a reasonable tapering strategy for discontinuing PPI therapy, particularly for patients without definitive ongoing indications for continuous acid suppression. 1
Rationale for This Approach
This tapering method addresses a key challenge when discontinuing PPIs: rebound acid hypersecretion (RAHS), which causes transient upper GI symptoms that typically resolve within 2-6 months. 1 By alternating a PPI with an H2-receptor antagonist like famotidine, you provide continued acid control while gradually reducing PPI exposure.
Evidence Supporting H2RA Use During PPI Tapering
- Famotidine does not interfere with the tapering process and can effectively manage breakthrough symptoms during PPI discontinuation. 2
- H2RAs like famotidine provide acid suppression for approximately 6 hours, with gastric pH beginning to increase within 30 minutes of administration. 2
- Famotidine is dosed at 20-40 mg once or twice daily for acid suppression in adults. 2
Important Caveats About H2RA Limitations
- Tachyphylaxis develops rapidly with H2RAs, typically within 6 weeks of continuous use, which limits their effectiveness for long-term therapy. 2
- H2RAs are less effective than PPIs for symptom relief and healing of erosive esophagitis. 2
- This limitation actually supports the alternating strategy rather than daily H2RA use, as intermittent dosing may delay tachyphylaxis development.
Who Should NOT Use This Tapering Strategy
Patients with definitive ongoing indications for PPI therapy should NOT discontinue or taper their PPI. 1 These indications include:
- Barrett's esophagus 1
- Severe erosive esophagitis (Los Angeles grade C or D) 2, 1
- High-risk patients requiring gastroprotection while on NSAIDs/aspirin, particularly those with: 1
- Age over 60-65 years
- History of upper GI bleeding
- Concurrent anticoagulants or multiple antithrombotics
- Concurrent corticosteroid use
- H. pylori infection
Recommended Tapering Algorithm
Step 1: Assess Appropriateness for Tapering
- Confirm there is no definitive ongoing indication for continuous PPI therapy. 1
- If PPI has been continued beyond 12 months without proven GERD, consider endoscopy with prolonged wireless pH monitoring off PPI to establish whether long-term therapy is appropriate. 2
Step 2: Implement Alternating Regimen
- Dexlansoprazole 30 mg every other day (on days 1,3,5,7, etc.) 1
- Famotidine 20-40 mg on alternate days (on days 2,4,6,8, etc.) 2
- Continue this pattern for 2-4 weeks 1
Step 3: Further Dose Reduction
- After 2-4 weeks, transition to on-demand PPI use only (taking dexlansoprazole 30 mg only when symptoms occur) 2, 1
- Use famotidine or over-the-counter antacids for breakthrough symptoms 1
Step 4: Monitor for Rebound Symptoms
- Expect transient upper GI symptoms from rebound acid hypersecretion, which can be managed with on-demand therapy. 1
- If severe persistent symptoms last more than 2 months after discontinuation, this suggests a continuing indication for PPI therapy and warrants reassessment. 1
Advantages of Dexlansoprazole for Tapering
Dexlansoprazole's unique dual delayed-release formulation provides two distinct drug releases, extending plasma concentrations and maintaining gastric pH control longer than conventional PPIs. 3, 4, 5 This extended pharmacodynamic effect may provide better symptom control during the tapering process compared to other PPIs. 3, 4
Patient Education Points
- Emphasize that PPIs are safe for GERD treatment and discontinuation should not be driven solely by concerns about potential adverse events. 2, 1
- Explain that temporary symptom recurrence during tapering is normal and does not necessarily indicate treatment failure. 1
- Document the rationale for tapering and ensure patients understand when to seek reassessment (severe symptoms persisting beyond 2 months). 1