Bad press about dementia and other side effects will raise more questions about appropriate use of proton pump inhibitors (PPIs) (omeprazole, etc). PPIs are popular because they're so effective and heartburn is common. But up to 70% of PPI use is probably unnecessary. And PPIs have potential harms. Long-term use is associated with fractures, C. difficle diarrhea, pneumonia, hypomagnesemia, and other risks.
Newer evidence suggests PPIs may be linked to an increase in dementia, heart attacks, and chronic kidney disease. Advise patients the absolute risks are low and primarily based on observational data, so they only show an ASSOCIATION not CAUSATION. But use this as another reason to advocate for judicious PPI use.
Think twice before suggesting a PPI for mild heartburn. Emphasize lifestyle changes, avoiding food and drink triggers, reducing stress, stopping smoking, weight loss if needed, etc. Also suggest trying an H2-blocker or antacid first. Keep in mind cases when PPIs really are needed and encourage short-term use if possible. Suggest just 4 weeks for duodenal ulcers or 8 weeks for gastric ulcers or erosive esophagitis. Advise saving long-term PPIs for patients who need them like chronic NSAID use, Barrett's esophagus, anticoagulant use after a GI bleed, etc. For further information, see topic on Recommendations for safety use of chronic NSAIDs.
For chronic or recurrent GERD, suggest using the lowest effective dose or a short course for just 2 to 4 weeks when symptoms recur. If patients have used a PPI for at least 2 months and are ready to stop, advise tapering over 4 to 6 weeks to minimize acid rebound. Recommend lowering the dose every week if needed then increasing the dosing interval each week to every other day, every third day, etc. Suggest using an H2-blocker for breakthrough symptoms if needed. Example of tapering over 4-6 weeks, if taking twice daily, shift to once daily. Next, take every other day. Then, take every third day. Then, continue to increase the interval between doses. Check why recently hospitalized patients are taking a PPI. PPIs for ulcer prophylaxis should be stopped after discharge.
REFERENCES
- Gomm, W., and others (2016). Association of Proton Pump Inhibitors With Risk of Dementia. JAMA Neurology, 73(4), p.410. Available at: https://pubmed.ncbi.nlm.nih.gov/26882076