Continue, Stop, or Taper the PPI?

Charles P. Vega, MD


October 25, 2019

In this edition of Cases in Deprescribing, I present another clinical scenario drawn from my own practice. I'll tell you what I plan to do, but I'm most interested in crowdsourcing a response from all of you to collectively determine best practice. So please answer the polling question and contribute your thoughts in the comments, particularly if you disagree with me.

Cliff (not his real name) is a 48-year-old man with a 3-year history of epigastric pain. His pain waxes and wanes, varying from dull to sharp—even "burning" at times—and is worse when he has eaten spicy food or fatty meals. Initial treatment with a histamine-2 receptor antagonist (H2RA) brought modest improvement. He was then started on a proton pump inhibitor (PPI) which more substantially improved his symptoms, allowing him to function normally. He has been taking omeprazole 40 mg twice daily for the past 2 years. He has indicated that he is satisfied with this treatment and wants to stay on the PPI. He says that missing a dose is "a kind of torture" because the pain bounces back the next day.

He's been obese for most of his adult life and has had little success maintaining healthy dietary changes or exercise regimens. He does not smoke and drinks one to two alcoholic beverages daily. An esophagogastroduodenoscopy performed 2 years ago was normal except for a small hiatal hernia. Helicobacter pylori testing and abdominal ultrasound done at that time were both negative.

On examination today, the patient exhibits mild epigastric tenderness without guarding. His body mass index is 35 kg/m2.


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