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Proton pump inhibitors — the step-down approach

Proton pump inhibitors (PPIs such as esomeprazole and omeprazole) are widely regarded to be safe medicines, but there is evidence to suggest that they can cause serious adverse effects. Recent studies reported that PPI use may increase the risk of C.difficile infection[1] or developing pneumonia.[2] Other studies found that long-term use of PPIs is a risk factor for hip fracture.[3,4]

Many patients who are prescribed a PPI for gastrointestinal reflux or dyspepsia don’t need to continue taking it in the long-term. They may be able to stop taking their PPI, or control their symptoms using a lower dose either daily or when symptoms occur. This is called the step-down-approach. It can be used when ongoing therapy is no longer needed (e.g., some people after discharge from hospital) and when an initial course of PPI therapy has healed inflammation of the oesophagus and controlled symptoms. By using the step-down approach, the beneficial effects of PPI therapy are retained, but the risk of side effects is reduced.

Some medicines may make dyspepsia worse. Stopping or reducing the dose of these medicines may mean that the PPI step-down approach can be used. You can find some examples of these medicines, and the PPIs used to treat gastrointestinal reflux or dyspepsia, in the What's what section at the end of this article.

Options for the step-down approach

Trial a withdrawal of PPI

Many patients will remain free of symptoms when PPI therapy is stopped. If symptoms recur, patients should take a low-dose PPI on the days when they are troublesome (symptom-driven therapy).

The ability of each patient to report the return of symptoms should be assessed before a trial withdrawal. Special consideration should be given to patients with dementia.

Ongoing, low-dose therapy

Continuous low-dose PPI can prevent relapse in patients with healed oesophagitis.

Symptom-driven therapy

Use a low-dose PPI on the days when symptoms are troublesome. On average, patients will take a PPI tablet about 2–3 times a week.

Patients whose symptoms are well-controlled by PPIs may be reluctant to reduce the dose or frequency of their medication. They may not be aware that there is less risk of unwanted side effects when less medicine is used, that their prescription costs could be lower, or that symptom-driven therapy will allow them to take fewer tablets. A brief description of these benefits may encourage patients to try.

Lifestyle changes should be used at the same time as PPI therapy — persevering with successful changes can help to reduce reliance on PPIs. Patients should be encouraged to eat healthily and to avoid foods that make their symptoms worse. Providing examples of dyspepsia-inducing foods, like spicy and fatty foods, can help patients understand what to avoid. If relevant, patients should be encouraged to quit smoking, moderate their alcohol consumption and lose weight. Patients that have symptoms at night may benefit from elevating the head of their bed.

Discuss the step-down approach with the prescribing doctor, or the pharmacist conducting a medication management review for your patients.

What's what

PPIs Brand name
Esomeprazole Nexium
Lansoprazole Zoton
Omeprazole Acimax, Losec, Meprazol, Omepral, Probitor
Pantoprazole Somac
Rabeprazole Pariet

Medicines that may make dyspepsia worse
(Below are examples only. This list is not exhaustive)
Brand name

Diltiazem (for angina or high blood pressure)

Cardizem, Coras, Diltahexal, Dilzem, Vasocardol

Nifedipine (for angina or high blood pressure)

Adalat, Addos, Adefin, Nifehexal, Nyefax, Nypine

Isosorbide mononitrate (to prevent angina)

Duride, Imdur, Imtrate, Isomonit, Monodur

Celecoxib (for pain relief)


Diclofenac (for pain relief)

Clonac, Diclohexal, Dinac, Fenac, Voltaren

Theophylline (for asthma or emphysema)


Prescribing Practice Review 45: Proton pump inhibitors: step-down to symptom control
PPR45: Proton pump inhibitors: step-down to symptom control
Go to the resource page.
Download PDF now
NPS Case Study 57 - Proton pump inhibitors: appropriate and safe use
NPS Case Study 57:Proton pump inhibitors
Go to the resource page.
Download PDF now.

Other useful resources


  1. Dial S, et al. JAMA 2005;294:2989-95.
  2. Laheij RJ, et al. JAMA 2004;292:1955-60.
  3. Yang YX, et al. JAMA 2006;296:2947-53.
  4. Targownik LE, et al. CMAJ 2008;179:319-26.
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