When Proton Pump Inhibitors Should Be Discontinued: American Gastroenterological Association Clinical Practice Update

Proton pump inhibitors (PPIs) are prescribed for various indications, sometimes with clear evidence-based benefit and sometimes with little to no proven benefit. The purpose of this clinical practice update from the American Gastroenterological Association is to provide best practice advice on when and how to de-prescribe PPIs used in ambulatory settings. 

Best practices: 

• Patients receiving PPI therapy should undergo a periodic review of the ongoing indications for use with their primary care physicians, who should document those indications. 
• Without a definitive indication for PPI use, consideration should be made to de-prescribe the medication.
• Most patients with a clear indication for chronic, twice-daily dosing of PPI therapy should be considered for step down to once-daily PPI therapy.
• PPI discontinuation should typically not be considered in patients with complicated gastroesophageal reflux disease (history of severe erosive esophagitis, esophageal ulcer, or peptic stricture).
• Withdrawal of PPI therapy should usually not be considered in patients with known Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis.
• Discontinuation of PPIs should only be entertained after patients are assessed for upper GI bleeding risk, using an evidence-based strategy.
• Discontinuation of PPIs should not be considered in patients at considerable risk for upper GI bleeding.
• Patients whose PPIs are de-prescribed should be advised that they may develop transient upper GI symptoms due to rebound acid hypersecretion.
• Discontinuation of PPIs can be tapered or performed abruptly.
• Patients should stop PPI therapy based on a lack of indication, not out of fear of PPI-associated adverse events.