Proton pump inhibitors (PPI) – patient guide

Patient guide: Proton pump inhibitors (PPI)

Proton pump inhibitors – also called PPIs or acid pump inhibitors – are a group of medicines that suppress the production of stomach acid. You may have been prescribed them for heartburn, peptic ulcers, acid reflux, or as protection if you take anti-inflammatory painkillers (NSAIDs). This guide explains what PPIs are, the difference between the most commonly used types, typical treatment courses, side effects, and how to taper off them safely.

For the clinical background article on long-term use and the underlying research figures, see our blog article on proton pump inhibitors.

What is a proton pump inhibitor?

The lining of the stomach contains small "acid pumps" that release hydrochloric acid into the stomach. The acid helps break down food and kills bacteria. When the pumps work too strongly – or when the lining of the oesophagus or stomach is irritated – the acid can cause heartburn, pain or ulcers. PPIs bind to the pumps and switch them off, so acid production drops sharply for up to a full day at a time.

The four most commonly used PPIs in Denmark are:

• Omeprazole (Losec and generics) – the first PPI and still the most widely prescribed worldwide.
• Pantoprazole (Pantoloc and generics) – the most prescribed PPI in Denmark measured by number of packs.
• Esomeprazole (Nexium) – chemically a close relative of omeprazole.
• Lansoprazole (Lanzo) – used among other things for Helicobacter eradication.

Omeprazole – the classic choice

Omeprazole reached the market in 1989 and is still first-line treatment for most indications. The standard dose is 20 mg once daily before breakfast. For more severe reflux or ulcers the dose can be raised to 40 mg daily or 20 mg twice daily. Omeprazole is available over the counter in packs of 7 and 14 tablets for short-term self-treatment of heartburn, while larger packs and higher strengths require a prescription.

Omeprazole is broken down in the liver by the enzyme CYP2C19, which means it can affect other medicines. The most important interaction is with clopidogrel (Plavix), where omeprazole can weaken the blood-thinning effect. If you take clopidogrel your doctor will usually choose pantoprazole instead.

Pantoprazole – fewer interactions with other medicines

Pantoprazole works fundamentally like omeprazole but has fewer interactions with other drugs. The standard dose is 40 mg once daily before breakfast, and 20 mg daily is often used for maintenance treatment. Pantoprazole is usually preferred if you:

• Take clopidogrel or other medicines that compete for the liver's CYP enzymes.
• Are being treated for HIV, epilepsy, or a transplant, where small fluctuations in blood levels matter.
• Have liver or kidney disease, where pantoprazole's more stable metabolism is an advantage.

In Denmark pantoprazole is only available on prescription.

Typical treatment courses

How long you need to be on a PPI depends on what you are being treated for. Treatment is always reviewed at the end of the planned period – not renewed on autopilot.

Condition	Typical dose	Duration
Uncomplicated heartburn	Omeprazole 20 mg or pantoprazole 40 mg daily	2–4 weeks, then a break
Acid reflux (GERD) without oesophagitis	Omeprazole 20 mg or pantoprazole 40 mg daily	4–8 weeks, then attempt at tapering
Oesophagitis (visible inflammation of the oesophagus)	Omeprazole 40 mg or pantoprazole 40 mg daily	8 weeks, follow-up gastroscopy for severe grades
Peptic ulcer (gastric or duodenal)	Omeprazole 20–40 mg or pantoprazole 40 mg daily	4–8 weeks, often combined with antibiotics for Helicobacter
Barrett's oesophagus	Omeprazole 20 mg or pantoprazole 40 mg daily	Ongoing maintenance therapy
Stomach protection during NSAID or blood-thinner treatment	Pantoprazole 20 mg or omeprazole 20 mg daily	As long as the risk-bearing medicine is taken

A PPI should always be taken 30–60 minutes before a meal – preferably breakfast – because the acid pumps are activated by food, and the medicine works best when it reaches the pumps while they are active.

Side effects with short-term use

Most people tolerate PPIs well. Short courses of 4–8 weeks most often cause:

• Headache in 2–5 % of users.
• Diarrhoea, constipation or bloating – usually temporary.
• Nausea or stomach pain in the first few days.
• Itching or rash – uncommon and usually resolves on switching to another PPI.

These effects normally fade during the first week. If they persist, your doctor can switch you to another PPI or adjust the dose.

Side effects with long-term use

If you have taken a PPI daily for more than a year, there are some longer-term effects worth knowing about. The figures are relative risk increases from large cohort studies – the absolute risk for the individual is usually small, but higher if you are older or have other illness.

• Vitamin B12 deficiency. Stomach acid releases B12 from protein in food. Up to 20 % of chronic PPI users develop measurable deficiency after several years. Tiredness, tingling in the hands or feet, and poor memory can be early signs. Have B12 measured every 1–2 years on long-term treatment.
• Magnesium deficiency. Rare, but can cause muscle cramps, palpitations and fatigue. The risk rises after one year of daily use.
• Bone fractures. A 35–55 % increased relative risk of hip and spine fractures with 2 or more years of daily high-dose use, mainly in older patients. Caused by reduced calcium absorption.
• Clostridioides difficile infection. Low stomach acid lets bacteria pass alive through the stomach. The risk is roughly double that of non-users.
• Pneumonia. A slightly higher risk in the first months of treatment, particularly in older patients.
• Kidney effects. A rare allergic kidney inflammation (interstitial nephritis) can develop insidiously. On long-term treatment, kidney values should be checked annually.

These risks do not mean that a well-indicated treatment should be stopped. The point is that PPI therapy should be reviewed every year: is there still a reason to continue?

Tapering – how to come off safely

If you have been on a PPI for more than 8 weeks and your doctor judges that the indication is no longer there, the treatment should be tapered down rather than stopped abruptly. When the acid pumps have been switched off for a long time, the stomach reacts with rebound acid production during the first 2–4 weeks after stopping. This causes heartburn that can be mistaken for the original condition coming back.

A typical tapering plan:

1. Weeks 1–2: Halve the dose (e.g. from 40 mg to 20 mg daily).
2. Weeks 3–4: Take the medicine every other day.
3. Weeks 5–6: Switch to antacids (Pepcid, Gaviscon, Samarin) or an H2 blocker (famotidine) as needed.
4. From week 7 onwards: Use acid-suppressing medicines only for specific symptoms.

Lifestyle adjustments help at the same time: weight loss if overweight, less coffee and alcohol, no large meals late in the evening, raising the head of the bed, and stopping smoking. Many people find that the need for PPIs disappears completely once these factors are in place.

When should you contact your doctor?

Contact your GP or the clinic if you:

• Have been on a daily PPI for more than 8 weeks without a planned review.
• Have recurring heartburn despite regular PPI treatment.
• Develop difficulty swallowing, pain on swallowing, or unexplained weight loss.
• Pass black, tarry stools or vomit blood – call emergency services or go to A&E.
• Experience new symptoms such as muscle cramps, tingling in hands or feet, or marked fatigue during long-term therapy.

For long-standing reflux or alarm symptoms a gastroscopy may be needed to assess the lining of the oesophagus and stomach. With a referral from your GP the examination is free under the Danish public health insurance.

In short

• Omeprazole and pantoprazole are both effective – pantoprazole is preferred when clopidogrel or other interacting drugs are also being taken.
• Take the tablet 30–60 minutes before breakfast.
• Most courses last 4–8 weeks. Long-term treatment should be reviewed every year.
• Always taper – do not stop abruptly – after long-term use.
• Have B12 and kidney values measured annually after one year of daily use.

CONTACT INFORMATION

Hans Edvard Teglers Vej 9, 1st floor. 2920 Charlottenlund

• Phone: +45 39 64 01 25
• Email: mail@kirurgen.dk

APPOINTMENTS

We answer the phone Monday–Thursday from 09:00 to 12:00.

FOR REFERRING DOCTORS

Provider number 215430