PPIs: when to take them and when to cut back

Why have I been prescribed a PPI?

PPIs are used for reflux and inflammation of the food pipe, stomach or duodenal ulcers, and as part of H. pylori treatment. They also protect the stomach in some people taking medicines that increase bleeding risk. In eosinophilic oesophagitis (EoE), they can help control inflammation even without heartburn.

PPIs can also help with dyspepsia: pain or burning in the upper tummy, feeling full too quickly or uncomfortable fullness after eating. They are more likely to help when acid contributes to the symptoms.

They reduce how much acid the stomach makes. They do not repair a hiatus hernia or stop every episode of fluid coming back up.

Three types of PPI are routinely available in New Zealand: omeprazole (Losec), pantoprazole (Panzop Relief) and lansoprazole (Lanzol Relief). Other brands or formulations may be supplied; check the active ingredient on your packet.

Reflux, PPIs and antacids

How should I take it?

For reflux, PPIs usually work best 30 to 60 minutes before a meal, often breakfast. If prescribed twice daily, take the second dose before the evening meal. Follow the instructions for your particular medicine. Regular use during the prescribed course gives the best acid suppression. PPIs reduce new acid production; they do not remove or neutralise acid already in the stomach. Antacids neutralise existing acid, which is why they can relieve symptoms more quickly.

Do not crush or chew coated granules or tablets. Ask your pharmacist about a suitable formulation if swallowing is difficult. Tell them about your other medicines, especially clopidogrel, which can interact with omeprazole. They can check which PPI is suitable.

What if PPIs aren’t working?

We can review why. I start with how you take the medicine, which symptoms remain and whether they are likely to come from acid. Sometimes adjusting the treatment helps; sometimes a different diagnosis or investigation is more useful.

Who may need treatment long term?

A short course, for example four to six weeks, may be enough for uncomplicated reflux. Ongoing treatment is often appropriate after severe reflux oesophagitis or a reflux-related narrowing, with Barrett’s oesophagus, when a PPI is controlling EoE, or when protection from an ulcer bleed is still needed.

Feeling better can mean the treatment is working. If you have one of these conditions, discuss a change with me or your GP first. We can still review the dose and use the lowest dose that provides the treatment you need.

Are PPIs safe? What about the things I have read?

PPIs have an excellent overall safety profile, including for long-term use when there is a good reason to continue. Most people tolerate them. Headache, nausea, tummy discomfort or loose stools can occur; tell your GP or pharmacist if these persist.

Some studies behind worrying headlines compare people who differ in age, health and other medicines. Those differences may explain the findings, rather than the PPI itself. Better-quality studies are reassuring. The table puts the less certain links and the recognised side effects into perspective.

What are PCABs?

Potassium-competitive acid blockers (PCABs) are another type of acid-suppressing medicine. They block the stomach’s acid pump in a different way from PPIs and can provide faster, sustained acid control. They are not currently available for routine prescribing in New Zealand (checked October 2026).

Can I reduce or stop it?

If symptoms have settled, we can review whether you still need daily treatment. Check the original diagnosis, any healing that needs to be maintained and whether you still need protection from bleeding.

The example below is for someone already taking high-dose omeprazole whose prescriber has agreed that reduction is appropriate. Start at your current dose; do not increase it to follow the diagram. We can agree the pace, often allowing two to four weeks at each lower dose, and slow down if needed.

If symptoms return or persist, you may need to restart a PPI at the lowest regular dose needed to control them. Review troublesome symptoms with me or your GP rather than repeatedly stopping and restarting without advice.

What can I do about rebound heartburn?

After regular PPI use, the stomach can temporarily make more acid when treatment stops. Symptoms can last days to a few weeks. This does not automatically mean you need lifelong treatment.

An alginate or antacid can provide short-term relief. Ask your pharmacist which product suits your other medicines and health conditions. Smaller evening meals, leaving two to three hours before lying down, and raising the head of the bed for night-time reflux may help.

If symptoms are severe, persist beyond a few weeks or keep coming back, contact me or your GP. You may need to return to a PPI, using the lowest regular dose that controls symptoms. We can also check whether further investigation would help.