Gastroesophageal Reflux Disease Management

Introduction to Tinnitus and PPIs

The American Gastroenterological Association recommends considering medication adjustments when tinnitus develops in patients on long-term omeprazole therapy, as the FDA drug label documentation and known mechanisms of drug-induced ototoxicity suggest a plausible connection 1

For patients requiring acid suppression but experiencing tinnitus with omeprazole, the European Society of Gastrointestinal Endoscopy suggests considering switching to a different PPI, though cross-reactivity may occur, or using H2 receptor antagonists as an alternative or adjunct therapy 2
Anti-reflux surgery, such as fundoplication, may be considered for selected patients with GERD who cannot tolerate medical therapy, as recommended by the Society of American Gastrointestinal and Endoscopic Surgeons 1

The American College of Gastroenterology recommends periodically reassessing the need for continued PPI therapy in patients on long-term treatment, as well as monitoring for signs of nutrient deficiencies, including vitamin B12, iron, magnesium, and calcium 2, 3
Using the lowest effective dose to control symptoms is recommended by the National Institute for Health and Care Excellence to minimize the risk of adverse effects, including tinnitus 1
Higher doses of PPIs (≥1.5 PPI pills/day) are associated with a greater risk of vitamin B12 malabsorption in a dose-dependent manner, and the risk of vitamin B12 deficiency also increases with longer use of PPIs, particularly beyond 2 years 3
Long-term PPI use can lead to vitamin and mineral deficiencies, including iron deficiency, especially with doses ≥1.5 PPI pills/day for ≥2 years, and magnesium deficiency with 71% higher risk compared to non-users 3
To minimize the risk of gastric mucosal atrophy with long-term PPI use, strategies include:
The following table summarizes the recommended monitoring and follow-up for patients on long-term PPI therapy:

Patient Population	Recommended Monitoring and Follow-up
All patients on long-term PPI therapy	Periodic reassessment of the need for continued therapy, monitoring for signs of nutrient deficiencies, and consideration of endoscopic surveillance in high-risk patients
H. pylori-positive patients	Eradication of H. pylori and monitoring for signs of gastritis and gastric mucosal atrophy
High-risk patients (e.g. those with extensive GIM, incomplete GIM, or a family history of gastric cancer)	Endoscopic surveillance and monitoring for signs of gastric mucosal atrophy and other adverse effects

Long-term PPI therapy should be regularly evaluated for appropriateness, and patients should be monitored for signs of nutrient deficiencies, such as iron, vitamin B12, calcium, and magnesium deficiencies, and for potential adverse effects, including gastric mucosal atrophy, as noted by the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 and other guidelines 9, 8
The risk of developing gastric mucosal atrophy with long-term PPI use is significantly influenced by H. pylori status, with H. pylori-positive patients on long-term PPI therapy showing a higher rate of developing atrophic gastritis, and the Maastricht IV/Florence Consensus Report recommends eradication of H. pylori in patients receiving long-term PPIs to heal gastritis and prevent progression to atrophic gastritis, with an evidence level of 1b and a Grade of recommendation of A 4, 10