Can you take a PPI forever?

Dear Dr. Roach: You have written about PPIs such as Prilosec, which I have successfully taken for over 10 years to fight a severe case of GERD with a small hiatal hernia.

What is your opinion on my long-term usage and continuing it forever? My gastro specialist seems to be of the “keep taking it” attitude because of its success, but aren’t there potential downsides? Is switching to an H2 blocker like Pepcid or Tagamet easier on the kidneys? — K.J.

Dear K.J.: All medicines have side effects, and it is worthwhile to examine the risks and benefits. You already know the benefit: a large improvement in quality of life.

The clearest risk is probably infection. Not being able to make stomach acid puts a person at risk for Clostridium difficile infection (severe diarrhea) and other infections. Malabsorption of nutrients, especially magnesium and vitamin B12, is so frequent that testing may be appropriate in people who take PPIs longterm. Calcium may also be affected, potentially increasing risk of osteoporosis. This also deserves screening in the appropriate people at risk.

The association between chronic kidney disease and long-term PPI use is controversial, and is probably small. Still, a periodic check of kidney function is wise. There is weak evidence for a small increase in dementia risk.

My preference for patients on long-term PPI is to try taking them off slowly and replace it with an H2 blocker, just as you suggest. It is effective for many, but there are some people who really need a daily PPI in order to not have significant daily symptoms.

It is up to the person, but the risk of serious side effects is small enough that the benefit outweighs it for most.