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October 20, 2026 · Brian Tapley, PharmD

How to Deprescribe PPIs: A Guideline-Based Guide for Consultant Pharmacists

Educational only, not medical advice. Clinical decisions belong to the treating prescriber and pharmacist.

Proton pump inhibitors (PPIs) were picked as a priority class for deprescribing guidelines because they are so widely used and overused. The 2017 Farrell guideline notes that GERD usually needs only 4 to 8 weeks of treatment, yet cites studies in which 40% to 55% of US and UK primary care patients had no documented ongoing indication. This page summarizes three primary sources: the Farrell guideline (with its deprescribing.org algorithm), the 2022 American Gastroenterological Association (AGA) Clinical Practice Update, and the 2023 AGS Beers Criteria.

Key takeaways

  • Start with the indication. The AGA says every PPI user's indication should be reviewed regularly and documented.
  • Lower the dose or switch to on-demand use (Farrell). Stepping down to an H2-receptor antagonist (H2RA) is a weaker alternative.
  • Follow up at about 4 and 12 weeks, and warn patients about transient rebound symptoms.

Who is a candidate for PPI deprescribing?

The Farrell guideline covers adults over 18 who take a PPI for GERD or esophagitis. Deprescribing can be considered after at least 4 weeks of treatment for heartburn, GERD, or mild to moderate (Los Angeles grade A or B) esophagitis, once symptoms have resolved.

The guideline's algorithm also recommends deprescribing for:

  • peptic ulcer disease treated for 2 to 12 weeks;
  • upper GI symptoms without endoscopy, with the patient symptom-free for 3 consecutive days;
  • ICU stress ulcer prophylaxis that continued past the ICU stay;
  • uncomplicated H. pylori treated for 2 weeks, with the patient now asymptomatic.

For older adults, the 2023 AGS Beers Criteria list PPIs as potentially inappropriate. They advise avoiding scheduled use for more than 8 weeks unless one of the exceptions below applies (strong recommendation).

Who should generally stay on a PPI?

  • Farrell: the recommendations do not apply to patients who have or have had Barrett esophagus, severe esophagitis (grade C or D), or a documented bleeding GI ulcer. The algorithm adds chronic NSAID users with bleeding risk. For these patients, continue the PPI or consult a gastroenterologist before deprescribing.
  • AGA: patients with complicated GERD should generally not be considered for discontinuation. Examples are a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture. The same applies to Barrett's esophagus, eosinophilic esophagitis, and idiopathic pulmonary fibrosis. Assess upper GI bleeding risk before deprescribing, and do not deprescribe in patients at high risk.
  • Beers 2023: the exceptions are high-risk patients (for example, on oral corticosteroids or chronic NSAIDs), erosive esophagitis, Barrett's esophagitis, a pathologic hypersecretory condition, and a demonstrated need for maintenance treatment, such as a failed discontinuation trial or failure of H2RAs.

For NSAID users, Farrell defines high GI ulcer risk as a previous complicated ulcer or 3 or more of these risk factors: age over 65, high-dose NSAIDs, a previous uncomplicated ulcer, and concurrent aspirin (including low-dose), corticosteroids, or anticoagulants.

Deprescribing options

The Farrell guideline recommends one of two approaches (strong recommendation, low-quality evidence):

  1. Lower the daily dose, or
  2. Stop and use the PPI on demand. The patient takes it daily until symptoms resolve, then stops until they come back.

As an alternative, it suggests stepping down to an H2RA (weak recommendation, moderate-quality evidence).

In the guideline's systematic review:

  • A lower dose did not significantly increase symptom relapse compared with a standard dose (RR 1.16, 95% CI 0.93 to 1.44).
  • On-demand use raised relapse risk (RR 1.71, 95% CI 1.31 to 2.23) but cut 3.5 pills per week. The algorithm puts this as about 1 in 10 patients having symptoms return.
  • An H2RA step-down raised relapse risk (RR 1.92, 95% CI 1.44 to 2.58). The algorithm puts this as about 1 in 5 patients.

Tapering. Farrell found no trials that adequately tested the best way to taper. Very low-quality evidence suggests abrupt discontinuation increases relapse, so the authors say it might be prudent to reduce to the lowest effective dose before stopping. Gradual options include:

  • twice daily to once daily;
  • high dose to low dose;
  • daily to every other day.

The algorithm says no taper is proven better than another, so pick the one most convenient and acceptable to the patient. The AGA likewise says tapering or abrupt discontinuation can both be considered. Most chronic users on twice-daily dosing should be considered for a step-down to once daily.

US note: the 2018 algorithm uses Zantac (ranitidine) as an example of an over-the-counter H2RA, but the FDA asked manufacturers to withdraw all ranitidine products from the US market on April 1, 2020.

Monitoring for rebound and symptom recurrence

The AGA advises warning patients who stop long-term PPI therapy that rebound acid hypersecretion may cause transient upper GI symptoms. Farrell notes that rebound is hard to tell apart from a return of the underlying GERD.

Suggested follow-up:

  • About 4 weeks: check for heartburn, regurgitation, epigastric pain, dyspepsia, or pain on swallowing.
  • About 12 weeks: check symptoms, how often on-demand doses are used, and whether further investigation or a return to continuous therapy is needed.
  • Residents who cannot report symptoms: the algorithm suggests watching for loss of appetite, weight loss, and agitation.

For occasional symptoms, the sources list on-demand PPI, an H2RA, antacids such as calcium carbonate, or an alginate. Non-drug measures are:

  • weight loss where appropriate;
  • no meals within 2 to 3 hours of bedtime;
  • raising the head of the bed;
  • avoiding dietary triggers.

If symptoms last 3 to 7 days and interfere with normal activity, the algorithm suggests testing and treating for H. pylori and considering a return to the previous dose.

Potential harms of long-term use

Much of the harm evidence is observational, so present it as associations, not proven causes.

  • Beers 2023: cites risk of C. difficile, pneumonia, GI malignancies, bone loss, and fractures. The panel rated the evidence as high for C. difficile, bone loss, and fractures, and moderate for pneumonia and GI malignancies.
  • FDA, 2012 (C. difficile): in most observational studies FDA reviewed, the risk was 1.4 to 2.75 times higher with PPI exposure. FDA advises considering CDAD when a PPI user's diarrhea does not improve.
  • FDA, 2011 (low magnesium): most cases came after more than a year of use, though some were reported after 3 months. FDA advises considering magnesium levels before and during prolonged therapy, especially with digoxin or diuretics.
  • FDA, 2010 (fractures): some epidemiological studies found a possible increased risk of hip, wrist, and spine fractures. The risk was mainly with high doses or use for a year or longer, and mostly in people 50 and older. FDA said it was not clear whether PPIs cause the increase.
  • Current pantoprazole labeling (2023): long-term daily acid suppression (for example, more than 3 years) may lead to B12 malabsorption.

The AGA adds a counterpoint. Base the decision to stop a PPI on the lack of an indication, not on fear of adverse events. A past adverse event, or risk factors for one, is not on its own a reason to withdraw a PPI that is indicated.

Consultant pharmacist checklist for a PPI regimen review

  1. Document the original indication, the start date, and any endoscopy, bleeding-ulcer, or NSAID history.
  2. Screen for "stay on" indications. These include Barrett's esophagus, severe or complicated erosive esophagitis, eosinophilic esophagitis, idiopathic pulmonary fibrosis, and a documented bleeding ulcer.
  3. Assess GI bleeding risk from NSAIDs, aspirin, corticosteroids, and anticoagulants.
  4. Flag twice-daily dosing for a possible step-down.
  5. Flag scheduled use past 8 weeks in older adults without a Beers exception.
  6. Suggest an approach to the prescriber: lower dose, on-demand use, or an H2RA. Include the relapse trade-offs.
  7. Plan follow-up at about 4 and 12 weeks, including nonverbal symptom checks.
  8. Write a relapse plan, and note related monitoring (magnesium with digoxin or diuretics, B12 with long-term use).

More practical notes are on the Insights page. For the data side of pharmacy work, see what a pharmacy informatics consultant does.

Try Consultant Pharmacist AIChat

Consultant Pharmacist AIChat is an educational AI chat from JQ GROW LLC for consultant and long-term care pharmacists. Use it to talk through deprescribing questions as you prepare a regimen review. It is not a pharmacist consult and does not replace clinical judgment. The account is free. Sending questions requires a $9.99/month subscription, which you can cancel anytime.

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FAQ

Should a PPI be tapered or stopped abruptly?
The AGA says either can be considered. The Farrell guideline found no trials showing a best taper. It suggests reducing to the lowest effective dose before stopping, because very low-quality evidence links abrupt discontinuation to more relapse.

How long can an older adult take a PPI under the 2023 Beers Criteria?
The Beers Criteria advise avoiding scheduled use for more than 8 weeks. Exceptions are high-risk patients (such as those on oral corticosteroids or chronic NSAIDs), erosive esophagitis, Barrett's esophagitis, a pathologic hypersecretory condition, and a demonstrated need for maintenance treatment.

What follow-up is recommended after deprescribing a PPI?
Farrell suggests checking symptoms about 4 and 12 weeks after the change. At 12 weeks, also review on-demand use and whether further workup or a return to continuous therapy is needed. Warn patients that transient rebound symptoms can occur.

Should a PPI be stopped because of fracture or C. difficile risk?
The AGA advises basing the decision on whether an indication remains, not on concern about adverse events. The FDA still advises using the lowest dose and shortest duration appropriate to the condition.

References

  1. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi P. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354-364. PMID: 28500192; PMCID: PMC5429051. https://pmc.ncbi.nlm.nih.gov/articles/PMC5429051/
  2. Deprescribing.org. Proton Pump Inhibitor (PPI) Deprescribing Algorithm. August 2018. https://deprescribing.org/wp-content/uploads/2018/08/ppi-deprescribing-algorithm_2018_En.pdf (resource page: https://deprescribing.org/resources/deprescribing-guidelines-algorithms/)
  3. Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022;162(4):1334-1342. doi:10.1053/j.gastro.2021.12.247. https://doi.org/10.1053/j.gastro.2021.12.247 (AGA summary: https://gastro.org/clinical-guidance/de-prescribing-proton-pump-inhibitors-ppis/)
  4. 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372. https://doi.org/10.1111/jgs.18372 (free full text: https://pmc.ncbi.nlm.nih.gov/articles/PMC12478568/)
  5. US Food and Drug Administration. FDA Drug Safety Communication: Clostridium difficile associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs). February 8, 2012. Archived copy: https://web.archive.org/web/20201222083139/https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-clostridium-difficile-associated-diarrhea-can-be-associated-stomach
  6. US Food and Drug Administration. FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs). March 2, 2011. Archived copy: https://web.archive.org/web/20200512162853/https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-low-magnesium-levels-can-be-associated-long-term-use-proton-pump
  7. US Food and Drug Administration. FDA Drug Safety Communication: Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. May 25, 2010; updated March 23, 2011. Archived copy: https://web.archive.org/web/20200320022731/https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-drug-safety-communication-possible-increased-risk-fractures-hip-wrist-and-spine-use-proton-pump
  8. PROTONIX (pantoprazole sodium) prescribing information. Revised July 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/020987s060%2C022020s023lbl.pdf
  9. US Food and Drug Administration. FDA Requests Removal of All Ranitidine Products (Zantac) from the Market. April 1, 2020. https://www.fda.gov/news-events/press-announcements/fda-requests-removal-all-ranitidine-products-zantac-market