SAN FRANCISCO — It may be appropriate to wean some patients from the daily use of proton pump inhibitors, but acid rebound can make this more difficult, David A. Peura, M.D., reported at the annual meeting of the American College of Physicians.
In his review of the evidence, Dr. Peura, professor of internal medicine at the University of Virginia, Charlottesville, drew a distinction between patients with gastroesophageal reflux disease (GERD) and those with the less serious nonerosive reflux disease (NERD).
Patients with NERD appear to have a much easier time discontinuing proton pump inhibitors (PPIs) or using them intermittently. In one study, 677 people with NERD who were asymptomatic after 2–4 weeks of PPI treatment were instructed to take a 2-week course of 20 mg of omeprazole, 10 mg of omeprazole, or 150 mg of ranitidine (a histamine2 receptor blocker) whenever symptoms developed (BMJ 1999;318:502–7).
During the year, 40% of patients had no relapses, and 90% of them required three or fewer courses of therapy to maintain satisfaction. This study influenced the dosing recommendation for over-the-counter omeprazole, Dr. Peura said.
On the other hand, weaning patients with GERD from daily PPI therapy may be difficult. An as-yet-unpublished systematic review from the Cochrane Collaboration concluded that about 80% of patients with GERD would experience a relapse of symptoms or esophagitis within 6–12 months if switched to a placebo.
“You can decrease that by giving an individual a half-dose treatment,” Dr. Peura said. “I personally never give half-dose PPIs because they're cost equivalent. The only reason you ever reduce the dose is if you worry about cost or safety. There's no safety issue with these doses, and they're flat priced.”
When PPIs are stopped abruptly in patients who have been treated long term with PPIs, there's often an acid rebound. According to one study, this effect appears to be restricted to patients who are negative for Helicobacter pylori infection (Gastroenterology 2004;126:980–8).
Dr. Peura said that tapering works better than abrupt withdrawal. “If I have somebody who's been on a drug for a while, I won't just stop it. I'll treat them every other day for a while, then every third day, trying to get them off the drug.” Tapering can be especially difficult in patients who have been taking twice-daily doses of a PPI, he said, making it important to use only the lowest effective dose.
Dr. Peura acknowledged serving on the speakers' bureaus of TAP Pharmaceutical Products Inc., AstraZeneca PLC, and Wyeth Pharmaceuticals, all of which make medications for gastric reflux.