Many taking twice daily proton pump inhibitors can step down

Question Do patients taking high doses of a proton pump inhibitor really need it?

Synopsis It's bad enough that many physicians routinely recommend an expensive proton pump inhibitor (PPI) for any patient with reflux, instead of initially trying an adequate dose of a histamine-2 antagonist (150-300 mg twice a day). Many patients also are bumped up to taking the drug twice a day because they have a little breakthrough discomfort. Although some people need more than the standard dose once a day, the authors hypothesised that many patients taking these agents in large or frequent doses could step down to standard dosing without any harm. For this prospective cohort study, they identified 298 consecutive patients at a Veterans Hospital in Ann Arbor, Michigan, who were taking a PPI for gastroesophageal reflux disease; those already taking standard dose PPI, with persistent symptoms on their current therapy, already taking a PPI for a reason other than gastroesophageal reflux disease, or who had alarm symptoms or cancer were excluded. That left 126 who were eligible for the heartburn clinic (really, a “let's reduce the dose of their medicine” clinic). Patients were evaluated and given a single dose of either lansoprazole 30 mg or omeprazole 20 mg 30 minutes before breakfast. The patients also received education regarding lifestyle modifications. If they still had no symptoms at two weeks, they returned at three months. If they were still doing well at three months, they were told to come back at six months, at which time they underwent another evaluation. If symptoms recurred at any point, patients were placed back on their original higher dose. At the end of six months, 77% had successfully stepped down to a single dose of PPI per day without any recurrence of symptoms.

Bottom line Most patients who have no symptoms when taking a high dose of a proton pump inhibitor (PPI) can be successfully stepped down to a standard dose of lansoprazole 30 mg or omeprazole 20 mg per day.

Level of evidence 2b (see www.cebm.net/levels_of_evidence.asp). Individual cohort study or low quality randomised controlled trials (< 80% follow up).