A 75-year-old woman with longstanding gastroesophageal reflux disease (GERD) comes to the office with concerns related to her new diagnosis of osteopenia. Her GERD is well controlled with once-daily pantoprazole, which she has taken without side effects for 1 year. She also takes calcium and vitamin D supplements. Other than her age, she has no additional risk factors for osteoporosis.
Her vital signs and the remainder of the physical examination are normal.
Which of the following is the most appropriate next step in management?
A. Attempt to discontinue or reduce pantoprazole
B. Continue pantoprazole at current dose
C. Obtain an upper endoscopy
D. Switch to ranitidine and metoclopramide
E. Switch to sucralfate
MKSAP Answer and Critique
The correct answer is A. Attempt to discontinue or reduce pantoprazole. This content is available to MKSAP 18 subscribers as Question 59 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate next step in management is an attempt to discontinue or reduce pantoprazole. Guidelines recommend that patients with symptomatic gastroesophageal reflux disease (GERD) syndromes without esophagitis be treated with a short course of a proton pump inhibitor (PPI) to achieve symptom control. Maintenance PPI therapy is recommended for patients with GERD who continue to have symptoms after the initial course of a PPI is discontinued, and for those who have erosive esophagitis or Barrett esophagus. In 2010, the FDA revised the prescription and nonprescription labels for PPIs to include possible increased risk for hip, wrist, and spine fractures. The FDA concluded that fracture risk was greatest with higher doses of PPIs or PPI exposure for 1 year or longer. The evidence associating PPI therapy with hip fracture was inconsistent, and guidelines recommend not stopping PPI therapy when it is otherwise indicated in patients at risk for osteoporosis. Other possible PPI-related adverse reactions include vitamin B12 and mineral (calcium and magnesium) malabsorption, as well as increased risk for community-acquired pneumonia, Clostridium difficile infection, and cardiovascular events. Many guidelines recommend that long-term PPI therapy be given at the lowest effective dose, which may include as-needed therapy. Other recommendations encourage an attempt to either reduce or stop chronic PPI therapy for uncomplicated GERD at least once per year.
Upper endoscopy is not indicated in patients whose GERD symptoms are controlled in the absence of alarm symptoms, such as dysphagia, weight loss, or anemia.
Prokinetic agents such as metoclopramide should not be used in the treatment of GERD unless gastroparesis is also present. Prokinetic drugs are no more effective than placebo, and these drugs can be associated with acute dystonic reaction and tardive dyskinesia. H2 blockers, such as ranitidine, can be used alone in patients without erosive esophagitis whose symptoms respond to H2-blocker therapy.
Sucralfate is sulfated sucrose complexed with aluminum hydroxide and can bind to damaged mucosa. It has been shown to prevent acute mucosal damage and heals chronic ulcers without altering gastric acid concentration or pepsin secretion. Sucralfate has no role in the treatment of GERD because, as with metoclopramide, studies have shown that it is no more effective than placebo.
- Long-term proton pump inhibitor (PPI) therapy for uncomplicated gastroesophageal reflux disease should be given at the lowest effective dose possible, and consideration should be given to reducing or stopping PPI therapy at least once a year.