1. Confirm indication
Check the original indication, gastroscopy findings and current dose. Treatment may be needed for symptom control, prevention of relapse, ulcer bleeding or other complications.
| Situation | Common indications | Practical approach |
|---|---|---|
| Long-term treatment | LA grade C/D oesophagitis, peptic stricture, Barrett’s oesophagus or PPI-responsive EoE | Long-term therapy may be indicated even when symptoms have resolved, to prevent complications. Follow the maintenance plan. |
| May continue | Reflux repeatedly returns after stopping, including non-erosive reflux | Use the lowest effective dose; intermittent treatment may suit milder disease. |
| Short course | Uncomplicated reflux or dyspepsia without alarm features | Optimise treatment for 4–6 weeks, then review. Reduce or stop if settled. |
| Treat then reassess | H. pylori eradication or uncomplicated peptic ulcer | Complete eradication and ulcer healing. Continue only if ulcer findings, NSAIDs or bleeding risk warrant it. |
| Gastroprotection | Previous ulcer bleeding with ongoing antithrombotics; two or more antithrombotics; NSAID/aspirin plus additional bleeding risks | Usually appropriate while risk persists. Consider age, ulcer history, other antithrombotics and oral steroids. A single anticoagulant or antiplatelet alone is not an automatic indication. |
Active upper-GI bleeding or an impacted food bolus needs urgent hospital assessment.
Red flags and referral
| Finding | Action |
|---|---|
| Bleeding or obstruction | Haematemesis, melaena, circulatory compromise or inability to swallow saliva: urgent hospital assessment. |
| Alarm symptoms | Progressive dysphagia, odynophagia, weight loss, iron deficiency anaemia, persistent vomiting or a mass: prompt investigation and gastroscopy consideration. |
| Higher cancer risk | New symptoms in an older adult, family history of upper-GI cancer or other gastric cancer risk: lower threshold for gastroscopy. |
| Persistent symptoms | Despite optimised PPI: consider gastroenterology assessment, gastroscopy or reflux monitoring. |
2. Optimise treatment
Take the PPI 30–60 minutes before breakfast; add a pre-evening-meal dose if prescribed twice daily. Heartburn is more likely to respond than regurgitation, early satiety or post-meal fullness.
For uncomplicated reflux, use a step-up then step-down approach. Start once daily; if symptoms persist after checking timing, adherence and the diagnosis, use a defined twice-daily trial rather than repeatedly switching. Once controlled, reduce to the lowest effective dose or intermittent/on-demand treatment for non-erosive reflux. Severe erosive disease, a peptic stricture or Barrett’s oesophagus usually needs maintenance treatment. Trials suggest that doubling the dose and switching PPI give similar average benefit, so repeated switching is rarely useful.
Dyspepsia without alarm features
Review medicines
NSAIDs (ibuprofen, naproxen, diclofenac), aspirin, iron, dabigatran, steroids and bisphosphonates may contribute. Check OTC use.
Consider H. pylori
Check prior testing and treatment. Consider stool antigen testing with ulcer history, increased infection risk or persistent dyspepsia. Confirm eradication after treatment.
Optimise PPI
Treat for 4–6 weeks where appropriate. Persistent symptoms may need gastroscopy or specialist advice.
H. pylori: medicine pauses before stool antigen testing
| Medicine | Minimum interval before testing |
|---|---|
| PPI | Two weeks without treatment, when clinically safe. |
| Antibiotics or bismuth | At least four weeks after the last dose. |
These medicines can cause false negatives. An antacid or alginate can help during the pause. Confirm eradication 4–8 weeks after treatment, allowing the same medicine intervals.
Sources: 15
Dose comparison and formulation
Practical adult reflux dose bands, not identical acid suppression or milligram-for-milligram equivalents.
| PPI | Usual daily dose | Higher-dose treatment |
|---|---|---|
| Omeprazole | 20–40 mg once daily | 20–40 mg twice daily |
| Pantoprazole | 40 mg once daily | 40 mg twice daily |
| Lansoprazole | 30 mg once daily | 30 mg twice daily |
Omeprazole can be increased to 40 mg twice daily in selected severe or refractory reflux. Higher doses for hypersecretory conditions need specialist management. For swallowing difficulty, check suitable formulations with the pharmacist; do not crush enteric-coated granules.
Does switching PPIs help?
One switch can help after checking adherence and timing, or for minor adverse effects. PPIs are the same drug class; there is no good evidence for repeated switches after one has failed.
With clopidogrel, pantoprazole may be more appropriate than omeprazole because it inhibits CYP2C19 less. Check other interactions before switching.
If symptoms persist after optimisation
Expected response in reflux and dyspepsia
| Condition studied | Typical response reported |
|---|---|
| Erosive oesophagitis | 70–80% complete symptom relief at about four weeks. |
| Reflux without visible inflammation | 50–60% complete relief at about four weeks; some study participants had non-acid symptoms. |
| Functional dyspepsia | 31% had no/minimal symptoms with PPI versus 26% with placebo, over 2–8 weeks. |
Different study populations and endpoints: symptom relief, not mucosal healing.
3. Put safety concerns in perspective
PPIs have an excellent overall safety profile. Observational links with dementia or osteoporosis do not prove causation. Recognised risks include enteric infection, rare acute interstitial nephritis and hypomagnesaemia.
Review long-term use periodically; six-monthly is a practical option. Consider magnesium, particularly with diuretics or digoxin. Check B12, renal function or other tests according to symptoms and risk factors, rather than a routine panel for everyone.
Useful figures when discussing safety
| Evidence | Clinical perspective |
|---|---|
| COMPASS trial: about three years | Fractures: 2.3% with pantoprazole versus 2.4% with placebo. Enteric infection: 1.4% versus 1.0% (about 4 extra per 1,000). Participants had cardiovascular disease. |
| NZ acute interstitial nephritis study | Hospitalisation/death: about 12 versus 2 per 100,000 person-years in current versus past PPI users. Rare; higher rates in older people. Can occur early or later. |
| Long-term renal effects | A later COMPASS analysis found slightly faster eGFR decline. The clinical importance remains uncertain. |
4. Review and consider step-down if appropriate
Continue, reduce or stop?
Continue
Maintenance or bleeding-prevention indication: continue the lowest dose that controls symptoms and prevents relapse or complications.
Reduce or stop
Settled symptoms and no ongoing indication: try once daily if taking twice daily, then consider stopping.
If symptoms return
Rebound symptoms may last a few days to a few weeks; an alginate or antacid may help. Persistent or recurrent symptoms: restart the lowest effective dose and consider investigation.
References
- bpacnz: reviewing and stepping down PPI treatment (2024)
- Healthify NZ: proton pump inhibitors (reviewed 2026)
- ACG guideline: reflux treatment and PPI safety (2022)
- AGA expert review: when and how to stop a PPI (2022)
- Randomised pantoprazole safety trial (2019)
- COMPASS kidney-function analysis (2024)
- NZ study: PPI use and acute interstitial nephritis (2014)
- ASGE reflux guideline: trial safety outcomes (2025)
- Medsafe: Panzop Relief (pantoprazole) data sheet
- AGA: personalised assessment of persistent reflux symptoms (2022)
- Cochrane: PPIs for functional dyspepsia (2017)
- ACC consensus: anticoagulant and antiplatelet treatment (2020)
- International consensus: nonvariceal upper-GI bleeding and secondary prevention (2019)
- bpacnz: dyspepsia assessment and alarm features (2011)
- bpacnz: H. pylori testing and treatment (updated May 2026)
- NICE CG184: reflux and dyspepsia in adults
- ACG: gastric premalignant conditions, including fundic gland polyps (2025)
- AGA: management of gastric polyps (2026)
- bpacnz: PPI prescribing, dose and interactions (2014)
- Medsafe: clopidogrel data sheet and PPI interaction
- NICE CG184: PPI dose bands (Appendix A; standard reflux and severe oesophagitis distinguished)
- Medsafe: Omeprazole (Teva) NZ data sheet, dose by indication