Recommendations

The Royal Australian College of General Practitioners

1.
Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.

PPIs are very effective and widely used medications for treating gastroesophageal reflux disease (GORD) and peptic ulcer disease. However, there is evidence of inappropriate prescribing, with a high proportion of patients kept on maximal doses long term. After initial symptom control, the lowest dose and frequency that provides ongoing symptom control should be reached by ‘stepping down’, and the medication ceased when no longer required. This reduces the risk of possible adverse effects to the individual, and the costs of long term treatment.

Adverse effects of long term use include increased risk of GI infection (incl. clostridium difficile), community acquired pneumonia, osteoporotic fractures, interstitial nephritis, and nutritional deficiencies (B12, Fe, Mg), particularly in the elderly or immunocompromised. Exceptions, for which prolonged treatment may be necessary, include Barrett's oesophagus, high grade oesophagitis, and GI bleeding.

The cost of anti-acid medication was $450 million in 2013–14, with prescription volume increasing 9% annually.

Recommendation released April 2015

Supporting evidence
  • Hughes JD1, Tanpurekul W, Keen NC, Ee HC. Reducing the cost of proton pump inhibitors by adopting best practice. Qual Prim Care. 2009;17(1):15-21.
  • www.nice.org.uk/guidance/cg184/chapter/1-recommendations
  • A. S. Raghunath, C. O’Morain & R. C. McLoughlin. Review article: the long-term use of proton-pump inhibitors. Aliment Pharmacol Ther 2005; 22 (Suppl. 1): 55–63.
  • T Ali, DN Roberts, WM Tierney. Long-term safety concerns with proton pump inhibitors. The American journal of medicine, October 2009 Vol 122, Issue 10, Pages 896–903
  • Reimer C. Safety of long-term PPI therapy. Best practice & research Clinical gastroenterology. 2013;27(3):443-54.