When short- or long-term use of PPIs is appropriate

Stopping chronic PPIs can be tricky due to acid rebound. Try to taper them over at least 4 to 6 weeks....

As a pharmacist, you should give more focus on reining in inappropriate use of proton pump inhibitors [PPIs] (omeprazole, etc) due to new expert guidance and payer restrictions. Washington State's Medicaid won't cover more than 2 months of a PPI per year without a prior auth. Other payers will likely consider similar limitations. This isn't surprising. Many patients use PPIs longer than they need to and chronic use is linked to fractures, C. diff, pneumonia, etc.

Help patients who need a PPI take it safely but have an "exit plan" to stop the PPI if it's no longer needed. Feel comfortable using PPIs long-term when potential benefits outweigh risks, prevention of NSAID-induced ulcers, chronic anticoagulant use after an upper GI bleed, Barrett's esophagus, etc. But re-evaluate PPI use periodically and use the lowest effective dose. Stick with PPIs short-term in many cases, such as just 4 weeks for a duodenal ulcer or 8 weeks for a gastric ulcer. At hospital discharge, also stop a PPI used for preventing stress ulcers, and question when patients are on a PPI and you don't know the indication.

Stopping chronic PPIs can be tricky due to acid rebound. Try to taper them over at least 4 to 6 weeks. For example, reduce the daily dose from omeprazole 20 mg BID to once daily for a week or more, then extend the dosing interval to every other day for a week or more before stopping. And use antacids or H2-blockers for breakthrough symptoms. Tell patients not to jump to PPIs for mild GERD. Advise trying an antacid or H2-blocker first plus diet and lifestyle changes. If an OTC PPI is needed, advise patients to try to limit it to just a short 2-week course or so, instead of staying on it long-term.

REFERENCES

Freedberg DE, Kim LS, Yang YX. The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017 Mar;152(4):706-715. doi: 10.1053/j.gastro.2017.01.031. PMID: 28257716.
Scarpignato C, Gatta L, Zullo A, Blandizzi C; SIF-AIGO-FIMMG Group; Italian Society of Pharmacology, the Italian Association of Hospital Gastroenterologists, and the Italian Federation of General Practitioners. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med. 2016 Nov 9;14(1):179. doi: 10.1186/s12916-016-0718-z
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar;108(3):308-28; quiz 329. doi: 10.1038/ajg.2012.444. Epub 2013 Feb 19. Erratum in: Am J Gastroenterol. 2013 Oct;108(10):1672. PMID: 23419381.