Advertisement

Strategies for Effective Discontinuation of Proton Pump Inhibitors

  • Judith Kim
  • John W. Blackett
  • Daniela Jodorkovsky
Esophagus (J Clarke and N Ahuja, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Esophagus

Abstract

Purpose of Review

Proton pump inhibitors (PPIs) are effective for many conditions but are often overprescribed. Recent concerns about long-term risks have made patients re-evaluate their need to take PPIs chronically, though these population-based studies have methodological weaknesses. The goal of this review is to provide evidenced-based strategies for discontinuation of PPI therapy.

Recent Findings

Given that some patients experience rebound symptoms when abruptly stopping continuous PPI therapy due to its effect on hypergastrinemia, strategies focus on avoiding rebound. Tapering the PPI and then initiating a “step-down” approach with the use of alternative medications may be effective. “On-demand therapy” provides patients with the option to take intermittent PPI courses, reducing overall use and cost while preserving patient satisfaction. It is important for providers to consider ambulatory pH or pH/impedance testing to rule out diagnoses that may require alternative medications like neuromodulators.

Summary

A number of studies reviewed here can provide guidance in counseling patients on PPI discontinuation. It is important for the provider to obtain a baseline needs assessment for PPI therapy and to elucidate predictors of difficulty in discontinuation prior to initiating a strategy.

Keywords

Proton pump inhibitors Hypergastrinemia Step-down therapy On-demand therapy Reflux hypersensitivity 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Forgacs I, Loganayagam A. Overprescribing proton pump inhibitors. BMJ. 2008;336:2–3.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Gawron AJ, Feinglass J, Pandolfino JE, Tan BK, Bove MJ, Shintani-Smith S. Brand name and generic proton pump inhibitor prescriptions in the United States: insights from the national ambulatory medical care survey (2006-2010). Gastroenterol Res Pract. 2015;2015:689531.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Katz MH. Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users. Arch Intern Med. 2010;170:747–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Moayyedi P, Delaney BC, Vakil N, Forman D, Talley NJ. The efficacy of proton pump inhibitors in nonulcer dyspepsia: a systematic review and economic analysis. Gastroenterology. 2004;127:1329–37.CrossRefPubMedGoogle Scholar
  5. 5.
    Wolfe MM, Sachs G. Acid suppression: optimizing therapy for gastroduodenal ulcer healing, gastroesophageal reflux disease, and stress-related erosive syndrome. Gastroenterology. 2000;118:S9–31.CrossRefPubMedGoogle Scholar
  6. 6.
    DeVault KR, Castell DO, American College of G. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100:190–200.CrossRefPubMedGoogle Scholar
  7. 7.
    • Freedberg DE, Kim LS, Yang YX. The risks and benefits of long-term use of proton pump inhibitors: expert review and best practice advice from the American Gastroenterological Association. Gastroenterology. 2017;152:706–15. Provides a critical review of studies suggesting PPI risks, allowing providers the ability to counsel patients effectively . CrossRefPubMedGoogle Scholar
  8. 8.
    Heidelbaugh JJ, Goldberg KL, Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care. 2010;16:e228–34.PubMedGoogle Scholar
  9. 9.
    Eid SM, Boueiz A, Paranji S, Mativo C, Landis R, Abougergi MS. Patterns and predictors of proton pump inhibitor overuse among academic and non-academic hospitalists. Intern Med. 2010;49:2561–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Lanas A. We are using too many PPIs, and we need to stop: a European perspective. Am J Gastroenterol. 2016;111:1085–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Mazer-Amirshahi M, Mullins PM, van den Anker J, Meltzer A, Pines JM. Rising rates of proton pump inhibitor prescribing in US emergency departments. Am J Emerg Med. 2014;32:618–22.CrossRefPubMedGoogle Scholar
  12. 12.
    Zink DA, Pohlman M, Barnes M, Cannon ME. Long-term use of acid suppression started inappropriately during hospitalization. Aliment Pharmacol Ther. 2005;21:1203–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Gomm W, von Holt K, Thome F, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol. 2016;73:410–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Targownik LE, Leslie WD, Davison KS, et al. The relationship between proton pump inhibitor use and longitudinal change in bone mineral density: a population-based study [corrected] from the Canadian Multicentre Osteoporosis Study (CaMos). Am J Gastroenterol. 2012;107:1361–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Furuya-Kanamori L, Stone JC, Clark J, et al. Comorbidities, exposure to medications, and the risk of community-acquired Clostridium difficile infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2015;36:132–41.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Lambert AA, Lam JO, Paik JJ, Ugarte-Gil C, Drummond MB, Crowell TA. Risk of community-acquired pneumonia with outpatient proton-pump inhibitor therapy: a systematic review and meta-analysis. PLoS One. 2015;10:e0128004.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA. 2013;310:2435–42.CrossRefPubMedGoogle Scholar
  18. 18.
    Roman S, Gyawali CP, Savarino E, et al. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil. 2017;29:1–15.CrossRefPubMedGoogle Scholar
  19. 19.
    Mainie I, Tutuian R, Shay S, et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut. 2006;55:1398–402.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Waldum HL, Arnestad JS, Brenna E, Eide I, Syversen U, Sandvik AK. Marked increase in gastric acid secretory capacity after omeprazole treatment. Gut. 1996;39:649–53.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    •• Reimer C, Sondergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137:80–7. 87 e81. Provides a mechanism behind the phenomenon of rebound symptoms with PPI discontinuation. CrossRefPubMedGoogle Scholar
  22. 22.
    Inadomi JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology. 2001;121:1095–100.CrossRefPubMedGoogle Scholar
  23. 23.
    •• Bjornsson E, Abrahamsson H, Simren M, et al. Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial. Aliment Pharmacol Ther. 2006;24:945–54. This randomized study found that certain factors like underlying diagnosis and gastrin level may affect ability for patients to discontinue PPI . CrossRefPubMedGoogle Scholar
  24. 24.
    Pace F, Tonini M, Pallotta S, Molteni P, Porro GB. Systematic review: maintenance treatment of gastro-oesophageal reflux disease with proton pump inhibitors taken ‘on-demand’. Aliment Pharmacol Ther. 2007;26:195–204.CrossRefPubMedGoogle Scholar
  25. 25.
    Bayerdorffer E, Bigard MA, Weiss W, et al. Randomized, multicenter study: on-demand versus continuous maintenance treatment with esomeprazole in patients with non-erosive gastroesophageal reflux disease. BMC Gastroenterol. 2016;16:48.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Hansen AN, Wahlqvist P, Jorgensen E, et al. Six-month management of patients following treatment for gastroesophageal reflux disease symptoms—a Norwegian randomized, prospective study comparing the costs and effectiveness of esomeprazole and ranitidine treatment strategies in a general medical practitioners setting. Int J Clin Pract. 2005;59:655–64.CrossRefPubMedGoogle Scholar
  27. 27.
    Murie J, Allen J, Simmonds R, de Wet C. Glad you brought it up: a patient-centred programme to reduce proton-pump inhibitor prescribing in general medical practice. Qual Prim Care. 2012;20:141–8.PubMedGoogle Scholar
  28. 28.
    Leiman DA, Riff BP, Morgan S, et al. Alginate therapy is effective treatment for GERD symptoms: a systematic review and meta-analysis. Dis Esophagus. 2017;30:1–9.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150:1262–1279.e2.CrossRefGoogle Scholar
  30. 30.
    Viazis N, Keyoglou A, Kanellopoulos AK, et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study. Am J Gastroenterol. 2012;107:1662–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Nguyen TM, Eslick GD. Systematic review: the treatment of noncardiac chest pain with antidepressants. Aliment Pharmacol Ther. 2012;35:493–500.CrossRefPubMedGoogle Scholar
  32. 32.
    Ligumsky M, Lysy J, Siguencia G, Friedlander Y. Effect of long-term, continuous versus alternate-day omeprazole therapy on serum gastrin in patients treated for reflux esophagitis. J Clin Gastroenterol. 2001;33:32–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Judith Kim
    • 1
  • John W. Blackett
    • 1
  • Daniela Jodorkovsky
    • 1
  1. 1.Division of Digestive and Liver DiseasesColumbia University Medical CenterNew YorkUSA

Personalised recommendations