Another Reason to Stop the PPI: Clinician Debate

Charles P. Vega, MD

Disclosures

October 13, 2020

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Recently, I posted a case drawn from my own clinical practice that involved a 60-year-old woman with gastroesophageal reflux disease (GERD). She has been taking a daily dose of a proton pump inhibitor (PPI) for years, with admitted symptom improvement. She now wishes to stop because of her concern that the drug increased her risk for COVID-19. My advice was to stop the PPI, but not because of COVID risk.

This case elicited a number of comments and ideas for which I extend my thanks!

This case was controversial, although the patient's risk for COVID-19 as a result of taking a PPI was clearly not the main theme of the conversation around the case. On that score, I agree with readers who emphasized that routine mitigation strategies, such as hand hygiene and physical distancing, are her most effective means to prevent COVID-19. Given our current state of knowledge, management of chronic medications is not as critical in reducing risk.

Most of the conversation focused on two things: the role of PPIs in GERD and need to rule out other potentially treatable conditions that might explain Virginia's GERD. I see patients like Virginia routinely, and it sounds like many of you do as well. Virginia was taking omeprazole 40 mg twice a day and, like many of you, I wondered why her previous clinician had elected to prescribe such a high dose. A fresh clinical perspective on a long-standing case can be helpful to see opportunities for improvement in care. Reevaluating the need to carry over an unnecessary PPI is a potential area for improvement. It is worthwhile to address this issue with more history and shared decision-making.

Her case provided some clues that there are steps other than PPIs or other acid-suppressing therapy that might improve her GERD symptoms. In addition to her PPI, Virginia was also taking frequent naproxen to treat her knee osteoarthritis. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are implicated in worsening GERD, and considering a different form of treatment, such as acetaminophen and/or a topical NSAID, can be beneficial for patients in the long term. In contrast, looking for Helicobacter pylori as a potential etiology for her GERD does not seem to be necessary because treating for this infection is not likely to improve GERD.

Most comments focused on the potential for weight loss to improve this patient's GERD. There were, maybe understandably, those who expressed doubt that she could accomplish meaningful weight loss. Of course, losing weight is one of the most difficult objectives for many patients, and it can be a source of severe frustration for patient and clinician alike.

But that rationale should not be a reason to ignore weight loss as an important goal among adults with obesity, even at age 60 years. In a clinical trial of a phased behavioral weight loss intervention among adults with cardiovascular risk factors, fully two thirds of participants who were aged 60 years or older were able to lose at least 4 kg during the 6-month trial. This compared favorably with adults aged 50 years or younger, half of whom lost a comparable amount of weight. Older adults were also more likely to maintain their weight loss compared with younger adults during the 30-month follow-up period.

This patient, worried about her risk for COVID, may be motivated to lose weight knowing that obesity is associated with a higher risk for complications from the disease. This could be a good point to note when initiating a behavioral weight loss program. But her expectations should be tempered, and any intervention to address weight should be realistic and able to be maintained long term. A crash weight loss program is unlikely to be either healthy or successful.

For this patient, the issue of bone health must be considered when advising weight loss as excessive weight loss might reduce bone density. However, the benefits of weight loss, as noted in multiple comments, will extend beyond probable improvement in her GERD. That makes this issue worth revisiting and certainly as least as important as her PPI therapy.

And let's not forget the reason she wanted to stop the PPI in the first place — her fear that it increased her risk for COVID. Although we don't have a definitive answer yet, it certainly appears that another benefit of discontinuing her PPI may well be that it reduces her risk for COVID-19. Clinical inertia in this case is a missed opportunity to reduce her burden of medications while improving her long-term health.

Charles P. Vega, MD, is a clinical professor of family medicine at UC Irvine and also serves as the UCI School of Medicine assistant dean for culture and community education. He focuses on medical education with an intent to resolve health disparities.

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