How GP practices can tackle potential PPI overuse

Proton pump inhibitors (PPIs) have become the established treatment for gastroprotection and upper gastrointestinal (GI) conditions, with millions of prescriptions issued every month. However, concerns have been raised about their inappropriate long-term use. Emma Wilkinson explores how this is prompting practices to review prescribing habits and identify opportunities for deprescribing or further investigation.

Proton pump inhibitors are one of the most frequently prescribed classes of medicines, but with concerns being raised by gastroenterology experts and prescribing leads about their overuse, practices are being encouraged to rethink their approach to the acid-suppressing drugs.

Proton pump inhibitors have been in use for more than three decades with omeprazole prescriptions tripling between 2006 and 2013. Open prescribing data show more than 6 million PPI prescription items are currently prescribed every month in England. Omeprazole and lansoprazole were among the five most commonly dispensed drugs in 2020, and some studies have suggested that about 15% of the population is prescribed a PPI at least once each year.

Potential harms from prolonged PPI use

As patients will attest, PPIs do work. There is strong evidence underpinning their use in upper GI disorders with excessive acid production and damage to upper gastrointestinal tissue.

They are also effective and commonly co-prescribed for gastroprotection alongside drugs known to cause GI bleeding, such as NSAIDs, oral anticoagulants and antiplatelets, with trials showing a significant decrease in the risk of ulceration and upper-GI bleeding. High-risk patients for whom PPIs may be prescribed also include those on antiplatelet treatment alongside other medicines known to increase the risk of bleeding, such as SSRIs or oral corticosteroids.

Yet they are not without risk and concerns continue to be raised, mainly based on observational studies, about long-term use. In addition to more routine side effects, including constipation and diarrhoea, reports have suggested prolonged use of PPIs may be associated with increased risk of fractures, C. difficile infections, community acquired pneumonia, vitamin B12 deficiency, hypomagnesaemia, dementia, acute interstitial nephritis and chronic kidney disease.

The BNF also includes a warning on PPIs that ‘very infrequent cases’ of subacute cutaneous lupus erythematosus have been reported in patients taking the drugs.

Why patients may end up on PPIs long term

Depending on the reason for taking the PPI, the benefits of the medicine may outweigh the risk, and this should be looked at on an individual basis, explains Dr Charlie Andrews, a GP with extended role in gastroenterology in Somerset who is on the committee of the Primary Care Gastroenterology Society (PCGS).

‘PPIs are very effective at managing heartburn symptoms and heartburn symptoms are very common,’ he notes. When given to protect the stomach lining alongside drugs such as clopidogrel, aspirin and NSAIDs, or to treat Barrett’s oesophagus, it is ‘absolutely the right thing to do,’ he says.

But there is a large group of patients who are symptomatic who are started on the drugs and stay on them.

‘It is hugely common, and once you are started on a drug it can be difficult to get off it, it stays on your repeat prescription and will often stay there for a very long time.’

GPs are also encouraged to prescribe PPIs in other scenarios, particularly for gastroprotection. Previous iterations of the PCN Impact and Investment fund, incentivised practices to ensure appropriate prescribing of gastroprotective medicines alongside NSAIDs, oral anticoagulants and aspirin.

The rebound effect

NICE guidelines recommend use of a PPI for four to eight weeks for adults with gastro-oesophageal reflux disease (GORD), with the lowest dose possible for recurring symptoms, and suggest patients can manage their condition using the drugs as and when needed.

What patients often do not realise, however, is that stopping a PPI after prolonged use for months or years creates a rebound effect – and this is a key reason people stay on them, according to Dr Andrews.

‘When patients come off it, often they will report that symptoms come flooding back, and so they see that as failure. They therefore go back onto it, and then they end up on the PPI long term,’ he says.

The solution is to wean patients off gradually. ‘If you stop suddenly you get rebound hyperacidity within the stomach and within several days the patient gets a surge of acid.’

Instead, Dr Andrews gives patients a plan to reduce the dose over the course of a month – reducing by 50% for a couple of weeks, then to taking on alternate days before stopping. ‘I also say to them that after this they can use it as and when needed, and it’s not unreasonable to go back on to it for several weeks to manage symptoms, but remember you can come back off it.’

Systemic factors contributing to PPI overuse

Aside from the rebound effect, there are a number of possible reasons so many patients have fallen into long-term PPI use against best practice. PPIs can be started during hospital admissions without clear indication or intended duration offered in discharge summaries. Reviews may not be a priority for overburdened practices.

Clinical software prompts, while useful for reminding clinicians of the need for gastroprotection, may be more cautious than guidance recommends, advising blanket PPI co-prescription with an NSAID irrespective of risk factors (such as age, history, dose of NSAID and concomitant prescription of drugs also associated with GI complications).

Another problem is that PPIs co-prescribed for gastroprotection may often be kept on repeat prescription long after the GI-risk drug has been stopped.

The withdrawal of ranitidine in 2020 and intermittent shortages of other H2 receptor antagonists also removed stepping-stone options, and patients switched to PPIs may not have had a plan to reassess.

There is also the possibility that over-the-counter availability of PPIs has shifted patient expectations around prescribing. For many, they may be seen as an easier and more effective solution to reflux symptoms than lifestyle changes and as-needed antacids, which can be obtained cheaply from the GP.

Setting expectations from the start

A good way to address the problem is to set clear expectations when initiating prescribing, says Dr Richard Stevens, another GPSI in gastroenterology and past chair of the PCGS, who contributed to a study examining PPI prescribing practices.

The research, based on patient records from 62 GP practices and reported in BJGP Open, found 62% of the 77,356 patients prescribed a PPI had no recorded indication, of which 40% had no medication review in the preceding year.

‘The important thing is to give the advice when you start the treatment, to make it clear that you shouldn’t [necessarily] be on these forever – so, we say to people, “we can probably get you better and then we should step the treatment down”,’ Dr Stevens says.

ICBs target high-dose and long-term prescribing

Hertfordshire and West Essex is among several ICBs that have set out guidance for practices on deprescribing of PPIs. Its guidance notes that the drugs are frequently prescribed without a clear indication or for prolonged durations without review, rather than following national guidance to prescribe them for the shortest possible time and at the lowest possible dose.

Long-term use in patients with gastro-oesophageal reflux should be limited to Zollinger-Ellison syndrome or Barrett’s oesophagus, the guidance states, and gastroprotection is not always required – patients should be individually assessed.

The ICB also notes that up to 30% of patients may be able to stop a PPI immediately after the initial course of therapy without experiencing symptoms. As of February 2025, the ICB had one of the highest rates in the country for use of higher-dose PPIs; its medicines optimisation team has worked with practices to look at how they initiate, review and deprescribe them.

Several other regions are pursuing similar work. Calderdale, which had also found itself above average for high-dose PPI prescribing, reduced its ranking on this measure from the 70th percentile to the 42nd between April 2022 and March 2024. Lancashire and South Cumbria ICB has also introduced a Primary Care PPI Review Pathway, as has Shropshire.

In Hampshire and the Isle of Wight, PPI deprescribing was included in a quality improvement project to reduce C. difficile infection rates: one PCN contacted 67 patients, with 48% responding. Of those, seven chose not to change their prescription, 11 arranged a telephone consultation, and 14 stopped without a consultation after following the guidance letter.

Pharmacists are key to ensuring appropriate review

But audits are not necessarily straightforward even for easily identified targets – such as those on PPIs for symptoms but never reviewed – and can be time-consuming. This work is most usefully done by a primary care pharmacist, says Dr Andrews.

‘Pharmacists play a really key role in this. Increasingly, they are carrying out medication reviews of patients on multiple medications. They need to be aware of the risks and able to counsel patients who can then make an informed decision, of whether they want to carry on.

Shveta Suri, head of pharmacy at NHS Derby and Derbyshire ICB agrees pharmacists can play an important role in identifying patients who may benefit from review and helping reduce prescribing risks where clinically appropriate as a way to ‘support wider patient safety’.

‘Some patients may remain on PPIs long term following initiation for acute indications, such as during hospital admission or for gastroprotection alongside short-term NSAID use, without an opportunity for subsequent review. Regular review can help ensure patients remain on the lowest effective dose appropriate for their clinical need,’ she explains.

‘Prioritising higher-risk patients or areas of greatest opportunity can help practices manage workload more effectively. Many practices may also find nationally funded prescribing analytics tools and dashboards, such as OpenPrescribing or Eclipse Live, useful in supporting targeted reviews.’

When to deprescribe

Dr Andrews has looked at long-term PPI prescription at his practice as part of a pilot run by Somerset, Wiltshire, Avon, and Gloucestershire (SWAG) Cancer Alliance, testing patients with risk factors (including long-term PPI use) using a capsule sponge test technique to detect Barrett’s oesophagus or signs of early oesophageal cancer.

The team searched their clinical system for patients aged over 50 with at least a six-month course of PPIs over a 24-month period, and invited them to undergo the test. Any patients found to have a cell abnormality (or inadequate sponge test) underwent endoscopy.

Overall, 7% of patients were found to have Barrett’s oesophagus. A further 11% had another underlying cause or condition such as H. pylori infection or hiatus hernia.

These are promising results and the approach is being further evaluated for a potential national programme to detect and prevent oesophageal cancer.

The project also uncovered a significant number of patients who had been on PPIs for a very long time but without a clear indication, and the team began to discuss the risks with these patients and whether they wanted to continue.

Ultimately, for these patients to have long-term relief from gastro-oesophageal reflux symptoms, lifestyle changes are necessary – but these can be hard to make and difficult for clinicians to advise on fully in a short appointment.

Dr Andrews says that in his experience, patients do not want to be on multiple drugs, and it is worthwhile to emphasise the benefits of lifestyle changes; he sends patients an evidence-based webinar to watch in their own time.

When referral may be warranted

As the SWAG initiative highlighted, there are also likely to be some patients with ongoing symptoms and other risk factors who may benefit from further assessment and potentially endoscopy.

‘Chronic GORD and PPI use in those over 50 should alert us to consider if endoscopy is indicated, to check for long-term changes such as Barretts or even early adenocarcinoma,’ Dr Andrews stresses.

‘This could be relevant to those carrying out medication reviews – for example, in a 58-year-old male smoker taking regular PPIs it would be sensible to be asking “are you still getting symptoms despite the PPI?” and “have you ever had an endoscopy?”.’

‘If the answers are “yes” and “no”, respectively, I would have a lower threshold for endoscopic assessment in these patients.’

With ICBs increasingly looking at the volume (and cost) of PPI prescriptions, and the potential harms of prolonged PPI use increasingly coming under scrutiny, GP practices may find PPI reviews a useful quality improvement initiative to undertake with their pharmacy or GP trainee colleagues.

Tackling potential PPI overuse in your practice

Ensuring appropriate prescribing of PPIs in new patients

Consider PPI co-prescription with an NSAID in people with one or more of the following risk factors:
- Age > 65.
- High dose (>300 mg) or need for prolonged NSAID, previous adverse reaction to NSAIDs.
- History of gastroduodenal ulcer, GI bleeding or gastroduodenal perforation (if already tested and treated if appropriate for H. pylori).
- Concomitant use of drugs known to increase risk of upper GI bleed including antiplatelets, anticoagulants, corticosteroids, SSRIs/SRNIs.
- Serious comorbidity such as CVD, diabetes, hypertension or hepatic or renal impairment.
- Heavy smoking or excessive alcohol intake.
Use the lowest effective dose for the shortest duration of treatment.
If started in hospital, clarify if continued prescribing required.
Ensure indication is clear in the patient record.
Arrange clear date for review if prescription is put on repeat.

Finding existing patients for review – identify and prioritise

Use OpenPrescribing or Eclipse Live dashboards to find patients on long-term PPIs without a recorded indication
Consider prioritising those on high-dose PPIs, elderly patients, those with C. difficile risk factors, or post-menopausal women with fracture risk

At review

Explore indication, dose and duration of PPI as well as underlying reason for prescribing.
If history of ulcer disease, test for H. pylori (if not previously done).
Ensure reviews encourage deprescribing if appropriate.
Where stopping is appropriate, wean gradually – for example, halve the dose for two weeks, then cut down to taking only on alternate days before stopping – to prevent rebound hyperacidity.
Reinforce dietary and lifestyle advice, including to limit intake of alcohol, coffee and acidic drinks, avoid spicy foods and eat enough fibre; signpost to NHS patient webinar for patients to watch in their own time.
Consider referral in symptomatic patients who wish to investigate further, or who have multiple risk factors, such as: age 50 years or older; white ethnicity, male sex; obesity; smoking; family history of Barrett’s or oesophageal adenocarcinoma.