There are a few reasons why patients are started on PPIs in the inpatient setting: in the setting of an acute upper GI bleed; long periods of no oral intake; high doses of steroids that require PPI prophylaxis. The problem is that when these patients are discharged, the PPI is often carried forward as a “new medication” that is then carried forward by outpatient providers, even if the indication for which they were started on PPIs has resolved.
PPIs should be continued in patients with Barrett’s esophagus, hypersecretory states (Zollinger Ellison), symptomatic GERD, and patients at high risk for bleeding (on NSAIDs, cirrhotics). But just because someone has had bleeding or a peptic ulcer doesn’t mean they have to be on a PPI for life! For low-risk patients with a first-time ulcer, you should reassess whether they need to continue a PPI 2 months afterwards. The PPI should be stopped when the acute indication has passed or, in the case of GERD, the patient has been asymptomatic for about 3 months. The lengths of time depends: Up To Date says, “As a general rule, active duodenal ulcers should be treated for four weeks and gastric ulcers for eight weeks.”
It is important to periodically assess whether a patient is a candidate for tapering and discontinuing their PPI because there are a number of downsides to PPIs:
- increased susceptibility to gastroenteritis and C. diff infections
- decreased absorption of vitamin B, iron, and calcium
- decreased calcium absorption then has implications for osteoporosis
- ?increased risk of aspiration pneumonia
Esophageal pH testing can be used to prove that someone does not have GERD, but it can be a bit cumbersome to arrange. The most important factors to consider are someone’s symptom profile and their risk for becoming symptomatic or bleeding in the future.
See this ACP Internist article about strategies for stopping PPIs. If a patient complains of “acid rebound” following taper of PPI, then they likely have symptomatic GERD and should actually continue their PPI.