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Step-down

Patients on proton pump inhibitors (PPIs) should step down or off their treatment if appropriate. However, reduced acid secretion caused by their PPI therapy can lead to increased gastrin production. In reducing or stepping off PPI therapy, gastrin levels remain elevated, resulting in rebound symptoms that can persist for up to 4–6 weeks. Investigate the step-down case below to understand how you can effectively step down patients from a PPI.

  • About the patient

    Anna, a 28-year-old office worker, has been taking 20 mg of omeprazole once daily for six months to manage her symptoms of reflux. After a recent medication review, she was advised to stop taking PPIs. Within days her symptoms return. She seeks medical advice, expecting to go back to PPI therapy.

  • Treatment goals

    Anna’s treatment should aim to help her step off PPI therapy. Most patients on PPIs should be considered for step down or off if possible. This is to:

    • Ensure your patients are not on medication for the rest of their life
    • Limit the potential mild side effects associated with long-term PPI use
    • Reduce the psychological impact of long-term medication use
    • Minimise costs related to PPI prescriptions
    • Follow guidance recommended by the National Institute for Health and Clinical Excellence (NICE) and the British National Formulary (BNF)

    Your relationship with your reflux patients should form the basis for deciding who to step down or off PPI therapy.

    The table below details examples of those who can be stepped down or off PPIs. This excludes patients who absolutely require ongoing PPI therapy for their gastrointestinal (GI) condition, such as those with proven Barrett’s oesophagus or erosive oesophagitis, proven erosive gastritis, complications of a GI bleed or gastric ulcer.

    PATIENT EXAMPLES
    Long-term PPI use for indications other than reflux that have resolved
    Provoked reflux with the cause addressed (e.g. pregnancy)
    Not reflux – incorrect diagnosis
    Patients with reflux who have responded adequately to PPI therapy
  • Challenges faced

    1. Rebound acid hypersecretion (RAHS)

      Patients stepping off of PPI therapy are likely to experience rebound symptoms. This is due to their increased gastrin production and can last for up to 4–6 weeks.

    2. Not all patients are able to step off

      Not all of your patients may be able to step off therapy. In these cases, maintaining PPI treatment may be required; however, ensure your patients wait 4–6 weeks before this decision is made.

  • Consultation advice

    You can initiate key treatment techniques to manage Anna’s symptoms and avoid her returning to PPI therapy.

    • Prescribe regular alginates

      As alginates do not interrupt acid production, they do not cause an increase in gastrin or rebound acid hypersecretion. Alginate therapy can help reduce Anna’s experience of rebound symptoms. You should advise her on how to take alginates appropriately, i.e. regularly after meals for 4–6 weeks.

    • Manage patient expectations

      You should ensure your patients understand that symptoms are likely to coincide with step-down. You can manage Anna’s expectations early, as well as educate her on the science behind her symptoms, to maintain her adherence.

    • Lifestyle advice

      Advise Anna on key lifestyle changes she can make, e.g. limit her alcohol intake to reduce her experience of heartburn.

    • Organise a review

      Be sure to organise a review with Anna after the six-week period to assess the success of her step-off process.

  • Resources

This content hub is funded by RB. The view and opinions presented here represent those of the doctors and do not reflect those of RB.

UK/G-NHS/0818/0015
Date of preparation: October 2018

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