Rebuilding trust in proton pump inhibitor therapy

Table 2 Guidelines on proton pump inhibitor use

ACG/ACG/CAG/SAGES/European guidelines	Recommendation
GERD[19,20,22]	Trial an 8-wk duration of once daily PPI in patients with heartburn and regurgitation without reflux symptoms
	Once daily dosing-administer PPIs 30 min to 1 h before a meal; twice daily dosing-administer PPIs 30 min to 1 h before breakfast and dinner
	For patients experiencing refractory GERD, optimize PPI therapy with patient compliance, dosage and timing to achieve symptom control before further exploration
	Prescribe continuous daily PPIs over H2RAs for erosive esophagitis maintenance healing
	Continue lifelong PPIs in patients with LA Grade C or D erosive esophagitis
	If patients with normal esophageal mucosa or LA Grade A esophagitis have normal ambulatory reflux monitoring results after 2-4 wk discontinuation of PPI therapy, it is strongly recommended to stop PPI use (low level of evidence)
Dyspepsia[23]	Patients < 60 years old, tested H. pylori negative or symptoms persist after eradication therapy, should start empiric PPI therapy
	Functional dyspepsia patients, tested H. pylori negative or symptomatic after infection treatment, should be on PPIs
H. pylori infection[24]	If active or history of PUD, and tested H. pylori positive, start eradication treatment (10-14 d) with PPIs and antibiotics
	Dyspepsia patients found to be H. pylori positive on gastric biopsy, treat with eradication therapy consisting of PPIs and antibiotics for 10-14 d
	GERD patients who are found H. pylori positive should be offered eradication therapy for 10-14 d course
	Use levofloxacin triple regimen consisting of PPI, amoxicillin and levofloxacin as salvage therapy if first line eradication therapy fails
Barrett’s esophagus[25, 26]	Recommend once daily dosing PPIs primarily indicated for symptomatic relief
	Twice daily dosing can be considered in patients with esophagitis or poor symptomatic relief
EoE [28,29]	Recommend PPI therapy for clinical and histological remission of EoE
NSAIDs[31,32]	PPIs are indicated for patients at risk of GI bleeds for gastroprotection (age > 65 years, high dose NSAID use, previous history of ulcers, concomitant therapy with corticosteroids, anticoagulants and antithrombotics)
	Prescribe continuous or intermittent high dose PPI the following 3 d after GI ulcer bleed was stopped endoscopically

ACG: American College of Gastroenterology; AGA: American Gastroenterological Association; SAGES: Society of American Gastrointestinal and Endoscopic Surgeons; CAG: Canadian Association of Gastroenterology; PPI: Proton pump inhibitor; H. pylori: Helicobacter pylori; H2RA: Histamine 2 receptor antagonist; GERD: Gastro-esophageal reflux disease; PUD: Peptic ulcer disease; LA: Los Angeles; EoE: Eosinophilic esophagitis; NSAID: Nonsteroidal anti-inflammatory drug; GI: Gastrointestinal.