Overuse of long term proton pump inhibitor medications

The problem

Long-term proton pump inhibitor (PPI) use is very common, but a substantial proportion is without an ongoing clear indication - overuse carries recognised, if generally modest individual, risks that warrant periodic review and deprescribing consideration
PPIs are among the most widely prescribed drug classes, and studies consistently find a large proportion of long-term users lack a documented ongoing indication, often having been continued indefinitely after an initial short-term prescription (e.g. for stress ulcer prophylaxis during a hospital admission, never subsequently stopped)

Chronic acid suppression alters gut flora and calcium/micronutrient absorption, and is associated (with varying strength of evidence, mostly observational rather than clearly causal) with: increased risk of enteric infection (including C. difficile), reduced calcium/magnesium/B12 absorption, community-acquired pneumonia, and (debated, weaker evidence) chronic kidney disease and fracture risk
Micronutrient deficiency (B12, magnesium, calcium/fracture risk), enteric infection risk (including C. difficile), rebound acid hypersecretion on cessation

Review the ongoing indication at each long-term prescription renewal - clear indications for continued long-term use include Barrett's oesophagus, severe erosive oesophagitis, and a documented high-risk NSAID/antiplatelet gastroprotection need; many other original indications (short-course dyspepsia, stress ulcer prophylaxis post-discharge) do not require indefinite continuation

Trial dose reduction or discontinuation where the original indication has resolved or was never a long-term one - rebound acid hypersecretion can occur on stopping (particularly after prolonged use), so a gradual taper rather than abrupt cessation, with the patient counselled about this expected transient symptom, improves success
Reassess if symptoms recur after a trial cessation - genuine ongoing need for acid suppression should prompt appropriate re-initiation rather than reflexive avoidance of PPIs altogether

PPI deprescribing is a specific, well-recognised example of addressing low-value/unnecessary long-term medication (see polypharmacy in older patients) - most patients on long-term PPI without a clear ongoing indication can be safely trialled off, with appropriate counselling about transient rebound symptoms

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