Using PPIs at Less Frequent Doses Than Once Daily

Appropriate Candidates for Less Frequent PPI Dosing

Patients with symptomatic esophageal syndrome without esophagitis can effectively use PPIs on an as-needed basis when symptom control is the primary objective 1
Patients with endoscopy-negative reflux disease may benefit from initial or on-demand treatment rather than daily maintenance therapy 2, 3
Patients without a definitive indication for chronic PPI use should be considered for de-prescribing or reduced dosing schedules 4

Patients with a history of erosive esophagitis should not use less than daily dosing of PPI therapy as maintenance therapy 5
Patients with complicated GERD should generally not be considered for PPI discontinuation or reduced dosing 6, 4
Patients with Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should maintain their prescribed PPI regimen 4
Patients at high risk for upper gastrointestinal bleeding who require gastroprotection should maintain their prescribed PPI regimen 4

For short-term therapy, PPIs are more effective than histamine receptor antagonists, which are more effective than placebo 1
On-demand therapy is a reasonable strategy in patients with an esophageal GERD syndrome without esophagitis 5
When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered 4
Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion 4

All patients taking a PPI should have a regular review of the ongoing indications for use, according to the American Gastroenterological Association 2, 4
Patients on twice-daily dosing should be considered for step down to once-daily PPI, as recommended by the American Gastroenterological Association 7, 4

Double-dose PPIs have not been studied in randomized controlled trials and are not FDA-approved, as stated by the American Gastroenterological Association 7
Higher-dose PPIs increase costs and have been more strongly associated with certain complications, including community-acquired pneumonia, hip fracture, and Clostridium difficile infection, according to the American Gastroenterological Association 7
The decision to discontinue or reduce PPI dosing should be based on lack of indication, not because of concern for potential adverse events, as recommended by the American Gastroenterological Association 4

Discontinuing PPIs in patients with strong indications for use may lead to symptom recurrence and complications, according to the American Gastroenterological Association 2
Using less than daily dosing in patients with a history of erosive esophagitis can lead to high rates of disease recurrence, as stated by the American Gastroenterological Association 5
Failure to recognize rebound acid hypersecretion when reducing PPI dosing may lead to premature resumption of full-dose therapy, according to the American Gastroenterological Association 4