Abstract
Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal
reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus,
prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs,
eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically
ill patients, and other indications. Best practice guidelines from several sources
on the appropriate indications and duration of PPI therapy have been summarized for
easy assimilation. Individualized decision with regard to PPI use is illustrated by
case vignettes; best approaches are provided.
The significant increase in use of PPIs for ill-defined indications over the years,
associated adverse outcomes with long-term use, and consequent increase in health
care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized
as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated
to acid inhibition include allergic reactions, acute interstitial nephritis, chronic
kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences
of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies,
fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth.
Provider awareness regarding best practice guidelines on PPI use and imparting pertinent
education to patients may be the rational approach to safe and effective PPI therapy.
In individuals in whom the drug is not indicated, efforts at deprescribing the PPI
may be attempted following discussion with the patient. Approaches include stopping
the drug, reducing the dose or using “on-demand” therapy after completing the course
of treatment for the specific indication. Barriers to successful deprescribing exist.
Follow-up is recommended for recurrence of manifestations; in the event of recurrence,
the PPI may need to be re-instituted.
PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain
disorders for specific durations of time. Evidence nevertheless suggests that excessive
and inappropriately prolonged use of PPIs is associated with a broad range of adverse
effects. Education of provider and patient, stewardship, and motivation are key to
appropriate use of PPIs for the right indications. Key implications for practice are
offered.
Keywords
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Article info
Publication history
Published online: December 14, 2020
Footnotes
The author declares no conflicts of interest.
The paper was written in response to a Call for Manuscript Submissions for a JAMDA theme issue on “Medication Use in Post-Acute and Long-Term Care: Challenges and Controversies.”
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© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
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