Do not wean off PPIs or make any changes in use without consulting a physician first! Make sure that you are closely monitored during the process of lowering your dosage of PPIs. It is also important to have doctors watch other medications you may take. The return of normal acid levels in the stomach can change the absorption level of many medications.
According to the American Gastroenterological Association, more than 60 million Americans experience acid reflux monthly, and up to 20% of those suffer from gastroesophageal reflux disease (GERD), a condition of chronic acid reflux. Heartburn is the pain caused by refluxed stomach acid irritating the esophageal lining. Antacids are usually sufficient in treating the majority of heartburn sufferers, but those with GERD are frequently prescribed a Proton Pump Inhibitor (PPI) by their primary care physician or gastroenterologist.
Get Off PPIs in 5 Steps:
- Gradually reduce the dosage by 25%-50% each week until you are taking half your current dosage. Wean off PPIs slowly to reduce the likelihood of acid rebound.
- Reduce intake frequency. If taking 2x daily, take once a day for a week. When at once a day, step down to every other day for a week.
- Change to an H2 blocker and wean down from H2 blocker to antacid using the same steps as in 1&2.
- At this point, occasional heartburn can be treated with antacids and an H2 blocker when necessary.
- Lifestyle and diet changes should be permanently maintained.
For the complete details on weaning off PPIs and the 5R Program for lifestyle modification, please read the complete article.
Misuse Of Proton Pump Inhibitors (PPIs)
While PPIs provide relief, they do not cure GERD. They only mask the problem by removing the pain associated with heartburn. If the medication is removed, the symptoms are likely to recur, thus proving this to be an ineffective treatment for GERD. The only way to cure GERD is for the sufferer to take an active role in managing the disease through a lifestyle change. Too many of us take the easy way out and do not take care of ourselves like we should. Eating healthy foods in proper proportions, limiting alcohol, and being physically active are some of the basic lifestyle changes that will eliminate GERD for most people.
Many who suffer from heartburn take PPIs without fully understanding how they are to be used. This is partly due to the lack of self-education on the part of the patient and a failure on the part of many caregivers to provide patients with proper instructions on how to take the drug. This lack of knowledge and fact that many PPIs are available as over-the-counter (OTC) medications lures patients into a false sense of security in the drug’s safety.
Too many patients continue taking PPIs for months or years because they do not understand the risks. In the United States, the packaging on OTC PPIs clearly directs taking it for no longer than 14 days or more often than every 4 months unless directed by a doctor. This is to prevent negative side effects that can occur when using the medication long term. Though your doctor may prescribe you a PPI for a different time interval depending on your health issue, they are to be taken short term and in the lowest dosage and interval possible to achieve the desired effect while healing from acid irritation takes place.
- Increased risk of heart attack.2
- Increased risk of pneumonia.
- Bacterial infections introduced through foods.
- Increased risk of a Clostridium difficile infection.3
- Decreased absorption of vitamin B12, calcium, magnesium, iron and other nutrients leading to bone fractures, hypomagnesemia, and cardiac arrhythmias.4,5
- Reduced ability of the lower esophageal sphincter (LES) to close due to low stomach acid levels. Higher acid levels are needed to induce the proper closure of the LES.
- Increased risk of Barrett’s esophagus which can lead to cancer.6
- Increased risk of esophageal cancer.
- Increased risk of chronic kidney disease.
- Increased risk of liver damage.
- Increased mortality risk.
[For greater details on long term use, side effects, and an understanding of the use of PPIs in treatment, please see the post “PPI – Proton Pump Inhibitor“.]
5 Reasons For Weaning Off PPIs
1. Long-term use of PPIs increases the risk of heart attack, kidney disease, liver damage, mortality, and more.
2. If you are exceeding the recommended dosage for PPIs, you are outside the FDA guidelines and are at risk of serious health issues.
3. If you initiated PPI medication without a doctor’s recommendation and supervision. Though PPI medication is available in OTC form, PPIs should not be taken without doctor recommendation.
4. If you are taking PPIs for regulating occasional acid reflux symptoms like heartburn… PPIs are not intended for the treatment of occasional acid reflux symptoms. Their best use is for stomach acid reduction to allow healing from acid erosion. There are other OTC heartburn medications better suited for treating acid reflux symptoms.
5. If you are breastfeeding, pregnant, or may become pregnant. PPI medication can expose the baby to risk.7
What Are The Side Effects Of Weaning Off PPIs?
The body is designed to produce stomach acid and will compensate for the drop of acid levels when using PPIs. Hypersecretion of stomach acid can occur when there’s a sudden discontinuation of PPI medication. In studies, this discomfort from over-production of acid affected 44% of patients lasting from one to three weeks. The rebounding of acid seems to be related to the degree of acid suppression.8,9 Therefore it is important to understand that this over-production of acid can occur, to be prepared for this possible side effect, and to slowly lower levels of your PPI when you wean off in order to minimize this problem.
Steps For Weaning Off PPIs
A. Understanding The Process Of Weaning Off PPIs
1. You should consult with a physician before making any change in PPIs and before implementing the 5R Program for Lifestyle Modification listed below. Your doctor can determine if these health steps are right for you. We are all different and modifications might be needed to accommodate your health conditions and any medications you may take.
2. Do not attempt to wean off your PPI if you are being treated for ulcers, acid damage, Helicobacter pylori, or other condition where PPIs are needed for treatment. Your doctor can help you make this determination.
3. The return of normal acid levels in the stomach can change the absorption level of other medications you take.
4. If medications are controlling your symptoms you may be able to reduce the dose of PPIs you’re on or wean off them altogether. GERD patients are often prescribed PPIs in dosage and frequency higher than needed. We are all different and the doctor is only making an estimate of what amount you might need to control your symptoms. If you are one of the many who’ve been overprescribed PPIs, symptom control may be achieved at a lower dosage, frequency, or even with a less potent form heartburn medication like an H2 blocker.
5. There are 3 levels of heartburn medications. They control the symptoms of heartburn but do not cure the underline cause of heartburn. If a lower dosage of PPIs or a lower level heartburn medication can treat your symptoms, it is important for your health to find the minimum level of treatment while still controlling heartburn.
- Level 1: Antacids help neutralize stomach acid. They act quickly but are short-lived, usually less than 2 hours. They are great for combatting the occasional heartburn brought on by ingesting heartburn trigger foods or drink.
- Level 2: Histamine receptor blockers (H2 blockers) decrease stomach acid production, thus decreasing heartburn due to acid reflux. H2 blockers can provide up to 12 hours of relief.
- Level 3: PPIs are used when antacids and H2 blockers aren’t providing relief. It may take days before they start providing relief, usually 48-72 hours.
6. We must understand that GERD is not caused by too much acid, but by acid being refluxed into the esophagus where it does not belong. Stomach acid can reflux when the LES doesn’t close properly. Acid is actually needed. It just needs to be in the stomach where it belongs. Acid triggers the LES to close keeping the acid out of the esophagus. Certain foods, overeating, abdominal pressure, medications, alcohol, nicotine, and obesity are the main offenders that can affect an otherwise properly functioning LES. These offenders can impair the lower esophageal sphincter’s ability to close properly allowing acid to reflux into the esophagus.
7. Lifestyle choices are tied to GERD in most cases. A positive change in diet, exercise, and stress levels will be required to wean off PPIs. This also includes a reduction in weight for many which will likely occur when the change in diet, exercise, and stress management are implemented.
8. It is important to make small gradual reductions when you’re weaning off PPIs.
9. Many are fortunate and can easily lower PPI dosages. Others are not as fortunate. Weaning off PPIs is not possible for those whose disease has progressed too far. These people will have to stay on PPIs. Remember PPIs do not cure GERD. They only mask the pain. GERD can still progress while taking PPIs. The goal when unable to stop taking PPIs is to find the right level of medication for your health and well-being and no more.
10. We are all different. What works for one may not work for another. It is important to take it slow and step back if your symptoms substantially increase.
11. It will be easier for people with less severe GERD symptoms to wean off PPIs and also easier for those who have taken the drug for a shorter time period and at a lower dosage than those with more severe issues who have taken high dosages for many years. There are even a significant number of long-term users taking PPIs for GERD who were misdiagnosed and don’t even need to be on the drug. This is primarily seen in those who did not have an endoscopy performed proving erosive esophagitis or a positive pH test. Weaning off PPIs will be easiest for those who were misdiagnosed.
12. Keeping a heartburn journal during this time will help you understand your triggers and any setbacks you have while you wean off PPIs.
13. The ultimate goal of this program is to wean off PPIs and return the stomach to proper function.
B. 5R Program For Lifestyle Modification When Weaning Off PPIs
If you have a proven diagnosis of GERD and have not changed your lifestyle, you will still have GERD when you wean off your PPI. This is because PPIs do not cure GERD. They control the pain of heartburn by reducing acid irritation. Heartburn will return if lifestyle changes aren’t implemented. GERD can only be corrected through diet, exercise, and stress management.
We can address the treatment of GERD by addressing the 5Rs of functional medicine: remove, replace, repopulate, repair and rebalance. Depending on your overall physical condition, the 5R Program should be in place one week to a month before you begin weaning off your PPI. Stomach acid is needed to properly break down food for absorption, so the dietary changes will become additionally effective when the stomach is back to producing acid at its optimal level.
Remove as many of the following heartburn triggers as possible…
Heartburn Trigger Foods
Remove heartburn trigger foods like processed food, fried food, fatty meats, dairy products, spicy food, the allium family (garlic, onions, shallots, leeks, and chives), tomatoes, acidic fruits, alcohol, coffee, caffeine, carbonated beverages, mint, chocolate, and candy containing acid in any form. Foods you are allergic to may also cause you heartburn and should be avoided. It would be good to keep a heartburn journal to log any other foods that might trigger your heartburn. We are all different and some food might cause you problems where they wouldn’t someone else. Heartburn trigger foods should be avoided because they can cause increased acid, irritation, and weaken the closure of the LES.
Most of us could stand to lose a little weight around the middle. Excess weight causes pressure on the LES.
Avoid tight-fitting clothes around your waist and stomach to prevent added pressure on the LES.
Poor Eating Styles
Do not overeat and smaller meals are best. Consider 4-5 small meals spaced throughout the day instead of the typical three. Eat slowly and chew properly. Putting the utensils down after each bite helps slow down eating. Following these eating guidelines will help aid the digestion process, let us know when we are full, and help us relax.
Remain upright during the day. Reclined and slouched positions cause stomach contents to press on the LES.
Nighttime Heartburn Triggers
Remove nighttime heartburn triggers by fasting 2 or more hours before bed, sleeping with your torso elevated by placing six-inch blocks under the head of your bed or by using a wedge pillow system or a mattress bed wedge will help stomach acids from refluxing, and lying on your left side which allows the stomach to hang lower thus preventing its contents from placing as much pressure on the LES.
Tobacco and Nicotine
Tobacco and nicotine include smoking tobacco, chewing tobacco, nicotine patches, and nicotine gum. These products cause irritation and relaxation of the LES along with other heartburn producing side effects.
OTC and prescription medications along with supplements may cause heartburn. It’s best to consult your doctor to see if some heartburn producing medications can be taken in the morning or hours before bedtime to reduce the chances of nighttime heartburn.
Learn how to de-stress.
When the heartburn trigger foods are removed, we are left to eat more nutritious foods which will boost our overall health and help us maintain a healthy weight.
Vitamins and Minerals
Consider taking a betaine hydrochloride supplement (Betaine HCl). Some people benefit from adding acid. Stomach acid aids in the proper function of the LES, breaks down food, and stimulates digestion. Avoid any betaine hydrochloride supplement containing NSAIDs or steroids. They can damage or irritate the digestive lining.
Low stomach acid levels can allow unhealthy bacteria to flourish in your gastrointestinal tract. Consider taking probiotic supplements and ingesting fermented food or drink containing probiotics to reintroduce them into your system.
Prebiotics are nondigestible carbohydrates that serve as a food source for probiotics. Prebiotics are available as a prebiotic supplement and in many foods such as artichokes, asparagus, bananas, barley, beets, carrots, flax, garlic, leeks, legumes, oatmeal, onion, radishes, wheat and more.
Popular forms of mucilage for repair are:
- Licorice in deglycyrrhizinated form, DGL.
- Aloe vera reduces inflammation and irritation. It also promotes healing, though it can serve as a laxative as well, so watch how much you take. You might look for some with the laxative component removed. Aloe vera can be purchased in a number of forms: juice, gel, powder, and softgels. Only use forms of aloe that are prepared for internal use.
- Slippery elm
- Marshmallow root
- Throat Coat Tea (Traditional Medicinals) contains licorice root, slippery elm, and marshmallow root.
Stress can increase sensitivity to acid and should be managed through exercise, enjoyable activities, soothing music, aromatherapy, meditation, prayer, massage, pets, friends, sex with a partner, laughter, sleep, etc.
Make sure you’re performing exercises that reduce heartburn risk and wait two or more hours after eating to avoid added pressure on the LES.
C. The Process For Weaning Off PPIs
There is no infallible way to know if you will be able to decrease or wean off PPIs without trying. We are all different and have to be treated as such when making medical choices. This is the main reason why it’s important to have your doctor approve and monitor your progress when weaning off PPIs. That said, weaning off PPIs has been successful in the majority of patients.10 If you have a rebound of heartburn during the following steps, back up in the process and take it slower. Also, consult your physician.
The basic steps to wean off PPIs:
1. Gradually reduce the dosage by 25%-50% each week until you are at 25%-50% of your current intake. If you go at 50%, this will take one week. If you go by 25%, this will take 3 weeks. The slower you wean off PPIs the less likelihood of acid rebound.
2. Once you are at a low daily dose, reduce the frequency at which you take the drug until you are off the PPI. If you are taking the PPI twice a day, step down taking it once a day for a week. When down to once a day, step down to taking it every other day for a week. If heartburn becomes severe, in either or both of these steps try substituting an H2 blocker where you once took the PPI.
3. Step down to the use of an H2 blocker and/or antacid once the above two steps have been completed. Though H2 blockers don’t have the severe side effects PPIs have over the long term, it is healthy to keep weaning down from H2 blocker to antacid use alone. Taper off the H2 blocker over the next 2-4 weeks using similar steps to those above.
4. At this point, you should be able to treat the occasional heartburn on demand with antacids or with antacids and H2 blockers when necessary.
5. Once you have weaned off the H2 blocker you may find you have no need for the mucilage. You can stop taking it or wean off of it as well.
D. Maintenance After Weaning Off PPIs
Remove and Rebalance, the first and fifth Rs of the 5R Program for Lifestyle Modification will have to be adhered to throughout your life to prevent GERD from recurring. The other three Rs need to be revisited where necessary. If you are adhering to the steps of Remove and Rebalance and heartburn becomes more frequent, revisit the other three.
In the Maintenance phase after weaning off PPIs, you should be able to take antacids or antacids and H2 blockers when necessary. You may also find natural heartburn remedies helpful. Don’t be discouraged if the occasional round of PPIs is needed in the future. When taking future dosages of PPIs, adhere to the acceptable amount recommended by the FDA taking it for no longer than 14 days or more often than every 4 months. Remember to always take the lowest level of medication you can while keeping your symptoms at your level of satisfaction.
Conclusion of How to Wean Off PPIs and Why
Don’t rush the process when weaning off PPIs. Remember, the longer you have taken them the longer you will want to take when weaning off to prevent an overproduction of acid. We are all different so consult your doctor before weaning off PPIs. Some people need to take them for longer periods of time than others.
1) Jai Moo Shin, PhD, & George Sachs, DSc, MD. “Pharmacology of Proton Pump Inhibitors.” National Center for Biotechnology Information, U.S. National Library of Medicine, Current Gastroenterology Reports – Springer, April 15, 2010.
2) Shah NH, LePendu P, Bauer-Mehren A, Ghebremariam YT, Iyer SV, Marcus J, Nead KT, Cooke JP, & Leeper NJ. “Proton Pump Inhibitor Usage and the Risk of Myocardial Infarction in the General Population.” National Center for Biotechnology Information, U.S. National Library of Medicine, PLOS One, June 15, 2010.
3) “FDA Drug Safety Communication: Clostridium difficile associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs).” U.S. Food & Drug Administration, March 23, 2011.
4) “FDA Drug Safety Communication: Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors.” U.S. Food & Drug Administration, September 24, 2015.
5) “FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs).” U.S. Food & Drug Administration, March 2, 2011.
6) Omran Alsalahi, & Anca D. Dobrian. “Proton Pump Inhibitors: The Culprit for Barrett’s Esophagus?.” National Center for Biotechnology Information, U.S. National Library of Medicine, Frontiers in Oncology, January 9, 2015.
7) Majithia R, & Johnson DA. “Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date.” National Center for Biotechnology Information, U.S. National Library of Medicine, January 22, 2012.
8) Christina Reimer, Bo Søndergaard, Linda Hilsted, & Peter Bytzer. “Proton-Pump Inhibitor Therapy Induces Acid-Related Symptoms in Healthy Volunteers After Withdrawal of Therapy.” Gastroenterology, July 2009, Volume 137, Issue 1, Pages 80–87.e1.
9) Anna Niklasson PhD, Lina Lindström MD, Magnus Simrén MD, PhD, Greger Lindberg MD, PhD, & Einar Björnsson MD, PhD. “Dyspeptic Symptom Development After Discontinuation of a Proton Pump Inhibitor: A Double-Blind Placebo-Controlled Trial.” The American Journal of Gastroenterology, March 23, 2010.
10) John M. Inadomi, Roula Jamal, Glen H. Murata, Richard M. Hoffman, Laurence A. Lavezo, Justina M. Vigil, Kathleen M. Swanson, & Amnon Sonnenberg. “Step-down management of gastroesophageal reflux disease.” Gastroenterology, November 2001, Volume 121, Issue 5, Pages 1095–1100.