If symptoms are controlled after an initial 4–8-week trial of a PPI, guidelines recommend that treatment is titrated down to the lowest dose and frequency that controls symptoms, or stopped.2
There are different options for ‘stepping down’ PPIs, and the approach should be individualised in consultation with the patient.
Patients can step down PPI medicines by
- taking the standard dose less often (for example, alternate-day dosing)
- reducing their PPI dose to a low dose
- or only taking PPIs ‘on demand’ when they experience symptoms.2
A patient may move between the different step-down options, depending on their level of symptom control.
If symptoms are well controlled, an attempt can be made to step down treatment further, or to stop. If symptoms return, the patient should step back up to the PPI dose that provided adequate symptom control.
Clinical studies investigating strategies for PPI discontinuation have shown that PPIs can be discontinued without deteriorating symptom control in up to 64% of patients.24 However, in the BEACH study mentioned above, just 23% of patients taking a PPI had attempted to reduce their dose in the last 12 months, and only 15% had attempted to stop.5
What if reflux symptoms are still not controlled?
If reflux symptom control is inadequate with a daily PPI, especially after treatment at the standard dose for at least 8 weeks, guidelines recommend that health professionals check with patients that they are taking their PPI regularly, and at the optimal time (30-60 minutes before meals).2
If adherence to therapy is confirmed, endoscopy is indicated to exclude other conditions.
Treatment with a PPI at a high dose may be considered if endoscopy supports a diagnosis of GORD.
For high-dose PPI treatment, guidelines note that a standard PPI dose given twice daily is more effective than a double dose given once daily.2
However, if symptoms still do not respond to PPI treatment, patients should be referred to a specialist for further investigation.2