Published: 7 June 2019

Publications

Proton pump inhibitors and rebound acid hypersecretion – A recurring issue

Prescriber Update 40(2): 36-37
June 2019

Key Messages

  • For many people, short-term proton pump inhibitor (PPI) use is appropriate.
  • Rebound acid hypersecretion has been reported in patients after stopping prolonged treatment with a PPI.
  • Consider a step-down approach when stopping PPI therapy.

Background

Concerns have been raised that rebound acid hypersecretion (RAHS) may be one of the explanations for the increasing long-term use of proton pump inhibitors (PPIs).

Proton pump inhibitors

PPIs inhibit gastric acid secretion. The PPIs currently available in New Zealand are omeprazole, lansoprazole or pantoprazole.

PPIs are indicated for1:

  • the short-term treatment of benign duodenal and gastric ulcers
  • the eradication of Helicobacter pylori, in combination with antibacterials
  • the treatment of dyspepsia and gastro-oesophageal reflux disease
  • the prevention and treatment of NSAID-associated ulcers
  • Zollinger–Ellison syndrome.

PPIs are widely used in New Zealand. In 2018, omeprazole was the third most commonly dispensed medicine, after paracetamol and atorvastatin2.

For many people, short-term PPI use (4–8 weeks) is appropriate. See the medicine data sheets for more information.

Rebound acid hypersecretion

RAHS is the recurrence of symptoms due to an increase in gastric acid secretion above pre-treatment levels after stopping PPI therapy3. Symptoms of RAHS may include heartburn, regurgitation or dyspepsia.

According to the proposed RAHS mechanism, reduced gastric acidity caused by PPIs induces hypergastrinemia and growth of histamine-releasing enterochromaffin-like cells, which leads to an increased acid secretory capacity once the PPI therapy is discontinued3.

Concerns have been raised that RAHS may contribute to the increasing long-term use of PPIs3. The symptoms of RAHS are similar to the underlying condition for which the PPI was used. Therefore, a reinforcing loop can develop where initial treatment creates the need for further treatment4.

Stopping PPIs

Consider a “step down” approach for people taking a PPI who are no longer experiencing symptoms and/or do not require long-term treatment2. Stepping down involves gradually reducing the dose over time, before stopping the medicine completely. Alternative treatments, such as histamine H2-receptor antagonists or antacids, may be useful to manage rebound symptoms.

See the Best Practice Advocacy Centre NZ (bpac) PPI stepping down protocol for more information.

References
  1. New Zealand Formulary. 2019. New Zealand Formulary v82.1: Proton pump inhibitors 4 April 2019. URL: https://nzf.org.nz/nzf_763 (accessed 10 April 2019).
  2. BPAC NZ. 2019. Stopping proton pump inhibitors in older people 24 January 2019. URL: https://bpac.org.nz/2019/ppi.aspx (accessed 15 March 2019).
  3. Lødrup A, Reimer C and Bytzer P. 2013. Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibitor treatment. Scandinavian Journal of Gastroenterology 48(5): 515–22. URL: https://doi.org/10.3109/00365521.2012.746395 (accessed 10 December 2018).
  4. BPAC NZ. 2014. Proton pump inhibitors: When is enough, enough? Best Practice Journal 61(June 2014): 8–15. URL: https://bpac.org.nz/BPJ/2014/June/ppi.aspx (accessed 7 December 2018).
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