Appropriate Use and Stewardship of Proton-Pump Inhibitors

Dylan Ren, 2020 PharmD Candidate; Erin Gurney, 2020 PharmD Candidate; Jaime R. Hornecker, PharmD, BCPS, CDE, DPLA


US Pharmacist. 2019;44(12):25-31. 

In This Article


GERD is one of the most prevalent acid-related disorders that require acid-suppressive therapy. PPIs have become the drug of choice for numerous patients and providers due to efficacy in symptomatic relief of GERD and other nonerosive reflux diseases. However, due to the underlying patho-physiological mechanisms responsible for GERD, PPI use typically requires chronic use and is not a curative therapy but may also be taken on an as-needed basis for the management of symptomatic flares.[11]

GERD also has the potential to develop or manifest into other conditions that require chronic PPI use. These include disorders such as Barrett's esophagus or esophageal strictures. In addition, erosive esophagitis may develop, in which PPIs remain an appropriate option for both the healing and maintenance of such an event.[11,12] The FDA does approve the use of PPIs in these aforementioned areas.

Zollinger-Ellison Syndrome and Pathological Hypersecretory Conditions

Zollinger-Ellison syndrome (ZES) is an acid hyper-secretory condition caused by a gastrin-secreting tumor.[12] PPIs are the FDA-approved drug of choice for management and must be given chronically to control acid secretion and prevent or reduce complications and symptoms in most patients with ZES.[12]

Stress Ulcer Prophylaxis

Although not FDA-approved, numerous guidelines recommend PPI use as prophylaxis therapy in hospitalized patients. Stress ulcers may occur in patients admitted to intensive-care units (ICUs), and inappropriate management or prophylaxis treatment may lead to severe events such as GI bleeding or ulcer formation.[11] Events such as GI bleeds may occur in up to 15% of patients not on stress ulcer prophylaxis (SUP).[11,13] Although SUP is critical to improve hospitalized patient out-comes, it should be stressed that PPIs are only approved for SUP in high-risk patients, defined as those who are critically ill and on mechanical ventilation for more than 48 hours, or those on anti-coagulation. [11] PPI use in these patients should be limited to short-term therapy as appropriate. PPIs should not be used as prophylaxis in low-risk or noncritically ill hospitalized patients.

Other Indications

PPIs are commonly used for a variety of other indications that do not carry an FDA approval. These include as add-on therapy for patients on antiplatelet therapy with high risk of GI bleed; functional dyspepsia; and prior to or following an endoscopy associated with an acute or high risk of bleeding.[7]