Table 1.

Appropriate prescribing of proton pump inhibitors: A) Evidence-based indications and duration for proton pump inhibitors, and B) indications for proton pump inhibitors based on gastrointestinal specialist advice.

A)
MAIN SYMPTOMSEVIDENCE-BASED INDICATIONHELICOBACTER PYLORI TESTING*INITIAL PRESCRIBING†LONG-TERM TREATMENTDEPRESCRIBING AND TOOLS
Heartburn or regurgitation dominantSymptomatic GERD15Not routinelySD: PPI once a day for 4 to 8 weeks, then reassess symptomsSome patients will require PPIs once a day or may need to step up to 2 times a day to maintain symptom controlYes—Figure 116
If symptoms are mild or worse for 2 days a week14If response is equivocal give PPIs 2 times a day for 4 to 8 weeks, then decide on possible long-term maintenance treatment
Epigastric pain or discomfort is dominantDyspepsia17Consider testingSD: PPI once a day for 4 to 8 weeks, then reassess symptomsSome patients will require PPIs once a day or may need to step up to 2 times a day to maintain symptom controlYes—Figure 116
Heartburn or regurgitation not dominant but may be presentIf response is equivocal give PPIs 2 times a day for 4 to 8 weeks, then decide on possible long-term maintenance treatment
Chronic users of NSAIDs with other risk factors‡: anticoagulation and ASA, or DAPTNAConsider upper GI bleeding prophylaxis: PPI once a dayDepends on indication and patient risk factor profileYes, once medications requiring PPI prophylaxis are discontinued (Figure 116). No, if high-risk patient‡
B)
EVIDENCE-BASED INDICATIONSH PYLORI TESTING*INITIAL PRESCRIBING†LONG-TERM TREATMENTDEPRESCRIBING OPPORTUNITY
Erosive esophagitis (confirmed by gastroscopy)Not routinelySD PPI once a day for 4 to 8 weeks, then reassess symptomsMany patients will need to step up to PPI 2 times a day for symptom controlYes, if grade A

No, if ≥ grade B
Peptic ulcer disease, duodenal or gastric ulcerRecommended: often done during diagnostic gastroscopy (consider ordering if not done)Uncomplicated ulcer: SD PPI once a day for 8 to 16 weeks Bleeding ulcer: PPI 2 times a dayYes, but not always. Bleeding ulcers need longer than 4 to 8 weeks of treatmentNo, not routinely. If considered, may require GI specialist
Barrett esophagusNoSD PPI 1 or 2 times a dayYesNo, lifelong PPI
Eosinophilic esophagitisNoSD PPI once a day or 2 times a dayOften yesNo, not routinely. If considered, may require GI specialist
Rare conditions
Hypersecretory conditions like Zollinger-Ellison syndromeNoSD PPI once a day or 2 times a dayYes, dose recommendation by GI specialistNo, lifelong PPI
Non-cardiac chest pain—presumed to be induced by GERDNot routinely. Requires gastroscopy, cardiac workup, and often esophageal motility testing, confirming there is no other cause explaining symptomsPPI 2 times a dayYesYes, may require GI specialist (Figure 1)16

  • AHS—Alberta Health Services, ASA—acetylsalicylic acid, DAPT—dual antiplatelet therapy, GERD—gastroesophageal reflux disease, GI—gastrointestinal, NA—not applicable, NSAID—nonsteroidal anti-inflammatory drug, PPI—proton pump inhibitor, SD—standard dose.

  • ↵* H pylori testing using H pylori stool antigen test or urea breath test. Treatment: antibiotics and PPI 2 times a day for 10 to 14 days. Many patients will still need long-term PPIs after H pylori treatment. For more information see the AHS H pylori pathway.18

  • ↵† Initial prescribing: For SDs, PPIs are considered therapeutically equivalent: pantoprazole, 40 mg; esomeprazole, 40 mg; lansoprazole, 30 mg; dexlansoprazole, 30 mg; omeprazole, 20 mg; rabeprazole, 20 mg.

  • ↵‡ Risk factors include age >65 y, taking anticoagulants, previous GI bleed, and upper GI symptoms. Reproduced with permission from Choosing Wisely Canada.16