By Cary Blum MD, Marty Fried MD and Shreya P. Trivedi MD || Illustration by Michael Shen MD. Quiz yourself on the 5 Pearls we will be covering:



What are associated adverse effects for patients are on long-term PPIs? (2:02 )

What are some strategies to get your patient off PPIs?  (10:57 )

How do histamine-2 (H2) receptor antagonists blockers work and how can it explain why H2 blockers might not be as effective as PPIs? (13:30 )

How should you educate patients to take PPIs to get the maximize benefit? (16:48 )

How do you manage ongoing symptoms in patients on PPIs? (21:41 )



Many thanks to Dr. Peter Stanich from the Division of Gastroenterology, Hepatology and Nutrition at The Ohio State University Medical Center for peer-reviewing this podcast!   

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To optimize learning, we are providing the podcast transcript to follow along with below:



M: A quick disclaimer –

C: In this episode, we assume more serious pathology has already been considered and ruled out, either by history or more advanced testing. And unless otherwise specified, in this podcast we are primarily referring to management of GERD.

[Sweeper – Pearl 1- Risks of PPIs]

S: Let’s start with a case to take us through our learning points.  Cary I think you had someone in mind when you developed the pearls for this podcast.

C:  I do – thanks Shreya!  My patient was a 74 year old man who had seen several providers in clinic.  He had multiple medical problems including, CKD, osteoporosis, some early cognitive impairment, and a problem list with its own table of contents–you know what I mean. Anyway, he had been on omeprazole 20mg for years and years, but from the past bunch of notes, I didn’t even know he had reflux. Turns out he hadn’t had symptoms in a long time.

M: Geez, there’s a lot to unpack there.  

S: Yeah I definitely feel you, Cary. More often that not, PPIs are on patients’ medication list and I haven’t started it myself.  So where did you start with this patient Cary?

C:   So first I had a tums myself because these elderly complicated patients can give even the best of us a bit of heartburn.  But seriously, I spent the first visit or two just getting a handle of his medical history, current and ongoing problems, and medications.  I realized pretty quickly that the PPI should probably be an early target to discontinue because he hadn’t had GERD symptoms in a long time, and I was concerned the PPI could be contributing to some of his medical problems.

M: Such an incrementalist Cary!

S: Let’s pause there and talk about some of the PPI-induced medical problems that you were worried about in this patient specifically but then also other side effects we should all be familiar with.

C: Right so when I think about adverse effects of PPI I divide them into two big buckets – those related to malabsorption and those related to infection.  

M: Nice I do like having a schema to organize these ideas.  Cary I’ve recently heard about chronic kidney disease associated with PPIs – that doesn’t seem like either malabsorption or infection.  How would you classify that?

C: Well, I should admit, there’s also likey a third “miscellaneous” category, of conditions that are associated with PPI use but the mechanism is very sketchy. CKD is in this category.  Its weakly but statistically associated with PPI use in observational studies but the absolute risk comes ou...