Long term use of PPI-indications and prevention of side effects

The use of proton pump inhibitors (PPIs) is generally recommended only for specific conditions such as severe erosive esophagitis, peptic stricture, Barrett’s esophagus, non-erosive GERD with ongoing symptoms, eosinophilic esophagitis responsive to PPIs, chronic esophageal mucosal diseases, certain peptic ulcer cases, prevention of bleeding in high-risk patients, and hypersecretory conditions.

When prolonged use is necessary, efforts should focus on using the lowest effective dose to manage symptoms and the underlying condition.

For patients not meeting the criteria for long-term PPI therapy, efforts should be made to discontinue these medications.

While PPIs have been associated with various adverse effects, evidence linking them to these conditions is primarily based on low-quality studies, and causation has yet to be definitively established.

More extensive studies have shown conflicting results, with minimal increases observed mainly in enteric infections.

Routine testing is generally unnecessary for those on long-term PPI therapy unless specific risk factors for certain conditions are present.

Let’s review those conditions and steps on how to manage our  patients if they need to stay on PPI therapy long-term:

   1. Ensure the patient has a strong indication for long-term PPI use. If not, consider deprescribing.

   2. If the patient warrants long-term PPI use, counsel the patient at the initial visit, emphasizing the following:

 • The patient has a medical condition that requires the use of long-term PPI, given its effectiveness for this condition. Discuss the rationale and efficacy of PPIs in patient education in this clinical context.

 •In general, when a medical condition warrants long-term PPI use, most providers would agree that the benefits of PPIs outweigh the potential risks.

  3. Use PPI at the lowest dose necessary to address patient symptoms or underlying conditions.

  4. For patients concerned about a particular adverse condition, consider the following:

 •Intestinal infections (ie, Clostridium difficile infection) (0%–0.09% per patient-year):

Emphasize the importance of hand hygiene and recommend cautious use of antibiotics unless indicated for an infection by a health care provider.

 •Osteoporosis (0.1%–0.5% per patient-year):

No risk factors are present: There is no need for routine bone mineral density assessment or the addition of calcium and vitamin D supplementation. Follow age-based osteoporosis screening guidelines and recommend daily calcium and vitamin D allowance.

Risk factors present: Consider baseline bone mineral density assessment and recommend lifestyle changes to reduce bone loss (calcium and vitamin D supplementation, smoking cessation). If osteopenia or osteoporosis is present, management with a primary care provider is recommended.

 •Chronic kidney disease (0.1%–0.3% per patient-year):

No risk factors present: No need for routine monitoring of creatinine.

Risk factors present: Consider once-yearly serum creatinine and nephrology consultation if chronic kidney disease is present.

Vitamin B12 deficiency and hypomagnesemia (0.3%–0.4% per patient-year):

No risk factors present: There is no need for routine serum vitamin B12 and magnesium monitoring or supplementation. Review symptoms of magnesium deficiency (muscle weakness, tremors, seizures, delirium, cardiac arrhythmias) and vitamin B12 deficiency (impaired balance, muscle weakness, numbness, and tingling) so patients can inform their provider if these symptoms arise.

Risk factors present: Consider assessment of serum vitamin B12 and magnesium levels once yearly and supplementation as necessary.

  5. Annual visits with patients on long-term PPIs to ensure they meet the indication for its use, the benefits outweigh potential risks, and the lowest possible dose is used.

Here is the link to the paper: https://www.cghjournal.org/article/S1542-3565(24)00195-2/fulltext

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