Proton Pump Inhibitors (PPIs) are widely considered the mainstay of medical treatment for GERD. Multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. This guideline provides updated, evidence-based recommendations and practical guidance of GERD.

When exercising clinical judgment, particularly when treatments pose significant risks, health care providers should incorporate this guideline in addition to patient-specific medical comorbidities, health status, and preferences to arrive at a patient-centered care approach.

Key Concepts

1. Regarding the safety of long-term PPI usage for GERD, guideline suggests that patients should be advised as follows:

“PPIs are the most effective medical treatment for GERD. Some medical studies have identified an association between the long-term use of PPIs and the development of numerous adverse conditions including intestinal infections, pneumonia, stomach cancer, osteoporosis-related bone fractures, chronic kidney disease, deficiencies of certain vitamins and minerals, heart attacks, strokes, dementia, and early death.

Those studies have flaws, are not considered definitive, and do not establish a cause-and-effect relationship between PPIs and the adverse conditions.

High-quality studies have found that PPIs do not significantly increase the risk of any of these conditions except intestinal infections.

PPIs might confer a small increase in the risk of developing these adverse conditions. For the treatment of GERD, gastroenterologists generally agree that the well-established benefits of PPIs far outweigh their theoretical risks.

2. Switching PPIs can be considered for patients who experience minor PPI side effects including headache, abdominal pain, nausea, vomiting, diarrhea, constipation, and flatulence.

3. For patients with GERD on PPIs who have no other risk factors for bone disease, guideline do not recommend that they raise their intake of calcium or vitamin D or that they have routine monitoring of bone mineral density.

4. For patients with GERD on PPIs who have no other risk factors for vitamin B12 deficiency, guideline does not recommend that they raise their intake of vitamin B12 or that they have routine monitoring of serum B12 levels.

5. For patients with GERD on PPIs who have no other risk factors for kidney disease, guideline does not recommend that they have routine monitoring of serum creatinine levels.

6. For patients with GERD on clopidogrel who have LA grade C or D esophagitis or whose GERD symptoms are not adequately controlled with alternative medical therapies, the highest quality data available suggest that the established benefits of PPI treatment outweigh their proposed but highly questionable cardiovascular risks.

7. PPIs can be used to treat GERD in patients with renal insufficiency with close monitoring of renal function or consultation with a nephrologist.