Proton pump inhibitors (PPIs) are commonly prescribed medications worldwide for the treatment of gastric acid-related diseases such as gastroesophageal reflux disease (GERD), Helicobacter pylori infection and gastric ulcers. 

However, the escalating prevalence of PPI overuse, especially for long-term therapy, has become a concerning issue.

Long-term PPI intake is associated with a reduction in intestinal absorption of essential vitamins and minerals and increased susceptibility to infections, chronic kidney disease and dementia. 

Given that PPI can inhibit gastric acid secretion, thereby affecting the intestinal absorption of essential minerals and altering the levels of calcium, magnesium and citrate, several studies have investigated the impact of PPI use on the risk of kidney stones.

PPIs reduce the absorption of minerals including magnesium and citrate. These minerals are needed to reduce the risk of kidney stones. Citrate is one of the key therapies for preventing stones. Low citrate levels increase the acidity of the urine and promote the crystallization of calcium in the urine.

To evaluate citrate levels, you need to order a 24-hour urine collection. If the citrate level is low and a patient is unable to come off PPIs, the treatment is potassium citrate, which replaces depleted citrate and alkalinizes the urine. The urine pH goal for treatment is a pH of 7.0 and above. Of note, 30 mEq of potassium citrate will raise urinary citrate by about 200 mg/24 hours. Be sure to monitor serum potassium levels.

Helping patients come off PPIs is not an easy task. Patients will often get rebound hyperacidity and feel worse before their body adapts to being without this drug. 

These are very useful medicines that are ideally used for short periods of time. If long-term use is required, the prescriber should be aware of strategies to prevent the harm of completely blocking acid production in the human body.