Recommendations for Long-term use of PPI for GERD

Both patients and physicians have a lot of questions about the safety of proton pump inhibitors (PPIs), a class of medications that have been a mainstay in the management of acid reflux disease (GERD) over the last 25 years. There have been reports in the media associating long-term PPIs with a number of problems. Given many patients have been on these medications for management of their GERD for year, they wonder if it is safe to continue on these medications long-term. Often they have tried to discontinue the medication but found alternative medication not as effective in controlling symptoms.

To help address these concerns,  a panel of gastroenterology experts recently published a review of the literature and proposed best practice advice about their use. They looked carefully at the all the available studies that have been published that have associated long-term PPI use with complications.  The list of problems attributed to PPI use have included dementia, osteoporosis, pneumonia, kidney disease, heart disease, GI infections and micronutrient deficiencies among others.  After analyzing the medical data, these GI experts concluded “Despite the long list of potential adverse effects associated with PPI therapy, the quality of the evidence underlying these associations is consistently low to very low. The benefits of PPIs likely outweigh the risks as long as they are prescribed appropriately.”

Here are some of the best practice guidelines that the expert panel felt may be helpful in the use of PPIs. These are sensible recommendations that are based on the best evidence about the risks and benefits of a class of widely prescribed medications.

 

  1. Patients with GERD and acid related complications like erosive esophagitis or peptic stricture should take long-term PPIs to achieve short term healing and maintain healing.

 

  1. Patients with Barrett’s esophagus with symptomatic GERD should be treated with long-term Patients with asymptomatic Barrett’s should be considered for long-term PPI use.

 

  1. Patients with uncomplicated GERD for whom PPIs are effective in the short term should try to stop or reduce PPI use. If they are unable to, further testing may be required to determine if longterm use is necessary.

 

  1. Long-term PPI dose should be evaluated periodically and the lowest effective dose should be prescribed.

 

  1. Patients with an increased risk of ulcer-related bleeding from arthritis medications such

as NSAIDS may require long-term PPI use.

 

  1. Due to lack of evidence in the reviewed literature, patients on long-term PPI use do not

routinely require monitoring of calcium, magnesium,  creatinine or bone mineral

density.

Reference: Freedberg et al. Gastroenterology 2017; 152:706