Clinical Question: Do patients taking high dosages of a proton pump inhibitor (PPI) really need it?

Setting: Outpatient (any)

Study Design: Cohort (prospective)

Synopsis: Many physicians routinely recommend an expensive PPI for patients with reflux instead of initially trying an adequate dosage of a histamine-H₂ antagonist (i.e., 150 to 300 mg twice per day). Many patients also are bumped up to twice-per-day dosing of a PPI because they have a little breakthrough discomfort. Although some patients need more than the standard dosage of a PPI once per day, the authors hypothesized that many patients taking these agents in large or frequent doses could step down to standard dosing without any harm.

They identified 298 consecutive patients at a Veterans Affairs Hospital in Ann Arbor, Mich., who were taking a PPI. Patients who were already taking standard dosage of a PPI, those with persistent symptoms on their current therapy, those already taking a PPI for some other reason, and those who had alarm symptoms or cancer were excluded. That left 126 patients eligible for the Heartburn Clinic.

Patients were evaluated and assigned to treatment with lansoprazole, 30 mg once per day, or omeprazole, 20 mg once per day, to be taken 30 minutes before breakfast. The patients also received education regarding lifestyle modifications. If still asymptomatic at two weeks, they returned at three months. If still doing well at three months, patients were told to come back at six months, at which time they had another evaluation. If symptoms recurred at any point, patients were placed back on their original higher dosage. At the end of six months, 77.1 percent of the patients had successfully stepped down to a single daily dose of PPI without any recurrence of symptoms.

Bottom Line: Most patients who are asymptomatic on a high dosage of a PPI can be stepped down successfully to a standard daily dosage of lansoprazole or omeprazole. (Level of Evidence: 2b)