AK Kamboj et al. Clin Gastroenterol Hepatol 2024; 22: 1373-1376. Long-Term Proton Pump Inhibitor Use: Review of Indications and Special Considerations

This article provides a good review on long-term use of PPIs. Table 1 provides indications that may require long-term use of PPIs:

• Erosive esophagitis: symptomatic Los Angeles Grade B or Maintenance for Grade C-D
• Symptomatic Nonerosive GERD
• Peptic stricture
• Biopsy-proven Barrett’s esophagus
• PPI-responsive esophageal mucosal diseases: eosinophilic esophagitis or lymphocytic esophagitis
• Peptic ulcer disease without modifiable risk factor
• High-risk patients receiving antiplatelet therapy
• Zollinger-Ellison
• Idiopathic pulmonary fibrosis (per pulmonologist)

Table 2 provides customary advice: ensure patient has a good indication for PPI otherwise consider deprescribing, and use lowest effective dose. It also summarizes potential adverse effects/management.

My take: The author’s “take-home message” is appropriate as a smartphrase for counseling patients (slightly modified below):

• Although proton pump inhibitor (PPI) use is common, only a few conditions warrant its long-term use. These conditions include severe erosive esophagitis, PPI-responsive eosinophilic esophagitis, chronic esophageal mucosal diseases, and peptic ulcer disease with risk of recurrence (and others).
• When PPIs are required long-term, efforts should be made to use the lowest possible dosing necessary to manage patient symptoms and underlying condition.
• In patients that do not meet indications for long-term PPIs, efforts should be made to deprescribe these medications.
• Although PPIs are often linked to various adverse conditions, these potential associations are largely based on low-quality studies and do not prove an increase risk for these conditions. Multiple larger-scale studies have also demonstrated results showing no such associations besides a marginal increase in enteric infections.
• In general, routine testing should not be performed on long-term PPIs unless risk factors for specific conditions exist. In those with risk factors, monitoring could be needed for low magnesium, vitamin B12 deficiency, chronic kidney disease, and osteoporosis.

Related blog posts:

• Austin Bradford Hill, PPIs and IBD
• Long-term Effects on Bone Health of PPIs in Infancy?
• Study: PPIs Did Not Cause Dementia in Older Adults
• PPIs: Good News on Safety (Part 2)
• PPIs: Good News on Safety
• AGA Blog: What are the complications of PPI Therapy?