Q&A

Taper proton pump inhibitor to once daily for GERD

J Fam Pract. 2004 January;53(1):8-24
By
John Zygiel, MD
James J. Stevermer, MD, MSPH
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  • BACKGROUND: PPIs provide very effective, but expensive, therapy for GERD. Many people start on more than once-daily dosing. The researchers report the results of a systematic attempt to reduce more frequent PPI dosing to just once daily.
  • POPULATION STUDIED: This study took place in the Veterans Administration Healthcare Center in Ann Arbor, Michigan, which includes several outpatient centers in the region. The researchers enrolled 117 subjects receiving more than 1 daily dose of a PPI—defined as more than 30 mg lansoprazole (Prevacid) or more than 20 mg omeprazole (Prilosec) daily—for the treatment of heartburn or acid regurgitation.
  • STUDY DESIGN AND VALIDITY: This study is a prospective cohort study. Identified patients were prescribed once-daily dosing of 30 mg lansoprazole or 20 mg omeprazole, half an hour before breakfast, as well as given instructions for lifestyle modification. Subjects were evaluated after 2 weeks, and those without recurrence of heartburn or GERD were followed at 3-month intervals for 6 months. (Those with recurrence were returned to their former regimen.)
  • OUTCOMES MEASURED: The primary outcome variable was the proportion of subjects without recurrence of heartburn or acid regurgitation after 6 months. Secondary outcomes included changes in health-related quality of life, pharmacy expenditures, and predictors of successful step-down. Quality of life was evaluated using 2 instruments: the 12-item Short Form Health Survey for generic quality of life, and a validated disease-specific measure not otherwise described.
  • RESULTS: Of the 117 patients participating in the study, 93 (79.5%) remained successfully stepped down after 6 months. All but 1 of the 24 failures occurred within 3 months of the dose change. Of subjects who had been on single-dose therapy prior to needing to step up to greater than single-dose treatment, 77.1% successfully stepped down. Of subjects who had never been on single-dose therapy, 82.1% successfully stepped down. Of 19 subjects who had previously attempted step-down unsuccessfully, 16 (84%) succeeded in establishing a single-dose regimen during the study, indicating that previous failure does not contraindicate a new attempt.
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PRACTICE RECOMMENDATIONS

For patients with gastroesophageal reflux disease (GERD) who take proton pump inhibitors (PPIs) more than once daily, an attempt to reduce dosing to once daily will be successful in over 80%, with little change in quality of life.

Given the expense of these medications, clinicians should undertake a trial of once-daily dosing for patients on higher doses, after their initial symptoms are controlled for at least 8 weeks. Though dose reduction is harder to achieve when patients have been taking a PPI long-term, 84% of such patients who could not tolerate an initial dose reduction were able to do so on a subsequent attempt.

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