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I have taken acid-blockers for years. What now?
Do not stop them suddenly, and do not assume you must take them for life. The first step is a review: why were they started, and is that reason still there? Some people need acid-blockers for the long term, and for them that is the right treatment. Many others can reduce the dose step by step under supervision.
In short
- Acid-blockers (proton pump inhibitors, or PPIs) are effective medicines, and they suit long-term use when there is a clear reason.
- Every long-term user should have that reason reviewed.
- Stopping suddenly often causes several weeks of rebound acidity, which is mistaken for proof that the medicine is still needed.
- The decision to reduce is based on whether you still need the medicine, not on fear of side effects.
- Tests can show whether acid is truly the cause of your symptoms.
Who should stay on acid-blockers?
For these groups, continuing is the safer choice:
- Barrett’s change in the food pipe
- Severe inflammation of the food pipe seen on endoscopy
- A past bleeding ulcer in someone who must continue aspirin, anti-inflammatory painkillers or blood thinners
- Certain less common conditions of the food pipe and stomach, as advised by your doctor
Who can try to reduce?
Reflux that is well controlled
Symptoms have been quiet for months, and the endoscopy showed no severe damage.
Indigestion that has settled
The medicine was started for upper abdominal discomfort that has since resolved.
Started in hospital and never reviewed
Often prescribed “for protection” during an illness and then continued for years.
No one remembers why
If no clear reason can be found, a supervised trial of reducing is reasonable.
How is the dose reduced?
Step down
Twice a day becomes once a day. Once a day becomes every other day, or only when needed.
Expect rebound, and plan for it
After years of acid suppression the stomach briefly overproduces acid when the medicine is reduced. This can last from two to eight weeks. An antacid or alginate after meals carries most people through.
Support the valve
An earlier, smaller dinner, raising the head end of the bed, weight loss around the waist and less alcohol reduce reflux at its source. See acid reflux.
Review
If symptoms return and stay beyond two months, the medicine is restarted at the lowest dose that controls them, and the reason is looked at again.
Are long-term acid-blockers harmful?
Studies have linked long-term use with lower vitamin B12, iron and magnesium levels, gut infections, fractures and kidney disease. Most of these links are weak, and they do not prove that the medicine was the cause. For people with a clear reason to take them, the benefits outweigh these risks.
Expert guidance is clear on one point: the reason to stop should be that you no longer need the medicine. Fear of side effects alone is not a reason.
In long-term users, particularly vegetarians, I check vitamin B12 from time to time.
What if my symptoms never fully settled?
Then the question is whether acid is the real cause. In people who have depended on acid-blockers for years, I have seen indigestion persist and bacterial overgrowth in the small intestine get worse.
Published studies are in line with this. In a pooled analysis of studies, the odds of bacterial overgrowth in the small intestine were about 1.7 times higher in people taking acid-blockers than in people who were not. An earlier analysis found the link only when overgrowth was measured directly, by culturing fluid from the small intestine. In a study of the stool of 1,815 people, those taking acid-blockers had less variety of gut bacteria and more bacteria of the kinds that normally live in the mouth. These are associations. They do not prove cause in any one person, and they are not a reason to stop a medicine that is needed. They are a good reason to review one that may not be.
Several things feel like acidity and do not respond to acid-blockers:
- An over-sensitive food pipe, or functional heartburn. See heartburn with a normal endoscopy
- Slow stomach emptying or functional indigestion
- Bloating and bacterial overgrowth, which push stomach contents upward
- Bile reflux
- A swallowing-muscle disorder
An endoscopy and a 24-hour pH study, done after a week without the medicine, show whether reflux is present. If it is not, the medicine can be stopped and the true cause treated.
When is surgery an option?
For people with proven reflux who respond to acid-blockers but do not wish to take them for life, or who still bring up food and fluid, keyhole anti-reflux surgery is an alternative.
Questions patients ask me
Is it dangerous to stay on acid-blockers?
For people who need them, no. The serious risks are small, and the conditions they prevent, such as bleeding ulcers and damage to the food pipe, are not. The aim is the lowest dose that keeps you well.
What happens if I stop suddenly?
Many people have rebound acidity for a few weeks. It is temporary. Stepping down gradually, with an antacid in reserve, makes it easier.
Should I take vitamins with my acid-blocker?
Not routinely. If you are on long-term treatment, have vitamin B12 checked, especially if you are vegetarian, and replace it if it is low.
Can I use home remedies in place of the medicine?
Meal timing, weight loss and raising the head of the bed have good evidence. Kitchen remedies soothe some people but do not heal an inflamed food pipe. See acidity home remedies.
I take a thyroid tablet. Does my acid-blocker matter?
It can. In studies, the blood test used to judge the thyroid dose rose after an acid-blocker was added, and the thyroid dose had to be adjusted. Do not stop either medicine. Tell the doctor who manages your thyroid.
Sources
This page is written for patients and is based on the guidelines and studies below. It is for education and does not replace a consultation.
- American Gastroenterological Association update on de-prescribing of proton pump inhibitors. Targownik LE et al. Gastroenterology. 2022. doi:10.1053/j.gastro.2021.12.247
- American College of Gastroenterology guideline on gastro-oesophageal reflux disease. Katz PO et al. Am J Gastroenterol. 2022. doi:10.14309/ajg.0000000000001538
- Lyon Consensus 2.0 on the diagnosis of reflux disease. Gyawali CP et al. Gut. 2024. doi:10.1136/gutjnl-2023-330616
- Review of lifestyle measures in reflux disease. Ness-Jensen E et al. Clin Gastroenterol Hepatol. 2016. PubMed 25956834
- Meta-analysis of acid-blocker use and bacterial overgrowth in the small intestine. Su T et al. J Gastroenterol. 2018. doi:10.1007/s00535-017-1371-9
- Meta-analysis of acid-blocker use and bacterial overgrowth in the small intestine. Lo WK, Chan WW. Clin Gastroenterol Hepatol. 2013. doi:10.1016/j.cgh.2012.12.011
- Study of acid-blocking medicines and the gut microbiome. Imhann F et al. Gut. 2016. PubMed 26657899
- Systematic review of acid-blockers and gut bacteria in sequencing studies. Macke L et al. Aliment Pharmacol Ther. 2020. doi:10.1111/apt.15604
- Study of acid-suppressing medicines and vitamin B12 deficiency. Lam JR et al. JAMA. 2013. doi:10.1001/jama.2013.280490
- American Gastroenterological Association practice update on functional heartburn. Fass R et al. Gastroenterology. 2020. doi:10.1053/j.gastro.2020.01.034
- Study of thyroid hormone dose in H. pylori gastritis, atrophic gastritis and acid-blocker treatment. Centanni M et al. N Engl J Med. 2006. doi:10.1056/NEJMoa043903
- Systematic review of acid-blockers taken together with thyroid hormone tablets. Guzman-Prado Y et al. J Gen Intern Med. 2021. doi:10.1007/s11606-020-06403-y