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Content Update

July 7, 2019

Updated Recommendation on the Long-Term Safety of Proton Pump Inhibitors (PPIs): In 2017, the American Gastroenterological Association (AGA) released best practice recommendations evaluating the risks and benefits of long-term proton pump inhibitor (PPI) therapy based on observational studies, including chronic kidney disease, dementia, bone fracture, myocardial infarction, Clostridioides difficile infection, other enteric infections, pneumonia, micronutrient deficiencies, and gastrointestinal cancer. This report stated that the risk of C. difficile infection was “modest” compared with traditional risk factors such as antibiotics. In the first and largest prospective, randomized trial examining the long-term safety of PPIs (specifically pantoprazole) published in 2019, after a median of three years of use, PPIs did not increase the risk of any of these adverse effects except for non-Clostridioides difficile enteric infections. The authors concluded that PPI therapy is safe for up to 3 years and that limiting prescription of PPI therapy because of concerns of long-term harm is not warranted.

Content Update

August 30, 2017

New Recommendations for Use of Proton Pump Inhibitors: The American Gastroenterological Association published an expert review and best practice advice for use of proton pump inhibitors (PPIs) in light of potential adverse effects associated with long-term use. Ten specific recommendations are provided for best practice advice. These articles provide information to assist health care providers assess the risks and benefits of long-term PPI therapy.


Patient Care Process for Peptic Ulcer Disease



  • Patient characteristics (e.g., age, sex, pregnant)

  • Patient medical history (personal and family) especially prior history of H. pylori infection, previous peptic ulcers, or previous upper GI disorders (see Table 33-4).

  • Social history (e.g., tobacco and ethanol use), as well as recent medical procedures and stress levels (see Table 33-2)

  • Current medications, especially NSAIDs (nonprescription and prescription) nonprescription use of proton pump inhibitors (PPIs), other nonprescription or prescription acid reflux treatments, anticoagulants, and antiplatelet medications. If prior NSAID use, note medication, dosage, and duration of use.

  • Pain: presence or absence, rating (1-10), quality, and location (see Table 33-5).

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation

    • Laboratory tests, including hemoglobin (Hgb), hematocrit, gastric acid secretory studies, and stool hemoccult

    • Urea breath test (UBT) for detection of H. pylori. Follow-up culture with endoscopy recommended (see Table 33-6)

    • Imaging studies: Upper endoscopy


  • Hemodynamic stability (e.g., systolic BP>90 mm Hg, HR>110 bpm, O2 sat<90%)

  • Presence of active gastric bleeding based on imaging studies

  • Presence of GI-bleed provoking factors (low platelets, anticoagulant/antiplatelet use, NSAID use, age >65, recent surgery, severe co-morbidities e.g., cardiovascular disease) (see Table 33-4)

  • Presence/absence of H. pylori

  • Emotional status (e.g., anxiety, depression, stress levels)

  • Ability/willingness to pay for ulcer treatment options

  • Ability/willingness to discontinue NSAIDs and switch to another pain reliever, if applicable

  • Ability/willingness to obtain laboratory monitoring tests (e.g., H. pylori status to ...

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