Is it acceptable to be on a Proton Pump Inhibitor (PPI) chronically?

From the Guidelines

Long-term use of proton pump inhibitors (PPIs) should be approached with caution and under medical supervision, with the goal of minimizing potential risks and maximizing benefits, particularly in terms of morbidity, mortality, and quality of life 1.

Key Considerations

• Chronic PPI use has been associated with potential risks including reduced absorption of nutrients, increased risk of certain infections, potential kidney problems, and bone density concerns 1.
• Long-term PPI therapy may be appropriate for certain conditions such as severe GERD, Barrett's esophagus, Zollinger-Ellison syndrome, or for patients requiring ongoing NSAID therapy with high bleeding risk 1.
• Patients without a definitive indication for chronic PPI use should be considered for a trial of de-prescribing, with regular review of ongoing indications for use and documentation of that indication 1.

Recommendations

• If long-term PPI therapy is required, the lowest effective dose should be prescribed, with consideration of periodic attempts at discontinuation or dose reduction, and monitoring for potential deficiencies 1.
• Alternative approaches such as H2 blockers, on-demand therapy, or lifestyle modifications may be beneficial in reducing acid reflux symptoms while minimizing medication exposure 1.
• Patients with a history of severe erosive esophagitis or GERD-related complications should generally not be considered for PPI discontinuation unless the benefits and harms have been weighed and discussed with the patient 1.

Important Notes

• The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for potential adverse effects associated with PPI use 1.
• Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion, and that on-demand PPIs, histamine type-2 receptor antagonists, or neutralizing antacids may be helpful in controlling symptoms 1.

From the FDA Drug Label

Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Avoid administration of PPIs for longer than medically indicated You should take omeprazole delayed-release capsules exactly as prescribed, at the lowest dose possible and for the shortest time needed. It is not known if omeprazole delayed-release capsules are safe and effective when used for longer than 12 months (1 year) for this purpose.

Chronic use of PPIs is not recommended. Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. The FDA label does not provide clear guidance on the safety and efficacy of long-term use of omeprazole delayed-release capsules beyond 12 months. Therefore, it is recommended to use PPIs for the shortest duration possible and to avoid long-term use unless medically necessary 2, 2.

From the Research

Adverse Effects of Chronic PPI Use

• The long-term use of PPIs may have significant adverse effects, including accelerating vascular aging 3.
• Long-term PPI use has been associated with a variety of adverse events, such as osteoporosis-related hip and spine fractures, community-acquired and nosocomial pneumonia, and various enteric and non-enteric infections 4.
• However, the quality of the evidence underlying most of these associations is very low and cannot ascribe cause and effect 5.

Safety Profile of PPIs

• PPIs are generally considered safe, but recent population-based studies have suggested that long-term PPI use may be associated with adverse events 4.
• Esomeprazole, a type of PPI, has been shown to be well tolerated with an adverse-event profile similar to that of other PPIs 6.
• A cross-sectional analysis of data from the National Ambulatory Medical Care Survey as well as a double-blinded, placebo-controlled trial report no safety concerns with PPIs, other than a possible small association with enteric infection 5.

Proper Prescribing Practice

• PPIs should be prescribed for valid indications and, when prescribed long-term, they should be used at the lowest effective dose and their ongoing need periodically assessed 5.
• Physicians should assist patients in tapering off their use of PPIs and replacing them with lifestyle modifications and/or other agents that have better long-term safety profiles 3.