Is Your Doctor Following the New ACG Guidelines for Prescribing PPIs?
By Stu Leo︱Published May 2, 2022
Did you know that PPIs have been misprescribed by nearly every kind of doctor you’d see for reflux since the 90s? It’s shockingly true!
In 1995, Dr. David Brandhagen observed, in a study published in the Journal of General Internal Medicine, that 56% of the PPI prescriptions given in one Minnesota hospital were inappropriate and wrong(PPIs were prescribed for stomach pain).
In 2007, a group of UK researchers conducted a clinical audit on a university hospital in Swansea, Wales, and found that 54% of patients were inappropriately prescribed PPIs.
In 2019, Dr. Joshua Boster wrote in the open-access journal Cureus that 66% of the patients at the Brooke Army Medical Center in Texas did not meet A guideline for appropriate PPI use.
And I could go on and on because there are literally hundreds of papers written on this subject. Needless to say, this is a serious problem because, as you may already know, PPIs could potentially raise your risk for osteoporosis, kidney disease, B-12 deficiency, pneumonia, stomach cancer, heart disease, dementia, stroke, and early death. Fantastic.
Why So Many PPI “Over-Prescriptions”?
A big reason why PPIs are being “over-prescribed”—or more accurately, misprescribed— is because different doctors have different guidelines for prescribing PPIs. In fact, it varies across the board from ENTS, to GI docs, to family docs.
For example, in the “Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)“, published in 2018, ENTS are given the thumbs up to prescribe PPIs to patients with hoarseness as long as they examine the inside of their throats with a laryngoscope and confirm reflux visually.
However, the American College of Gastroenterology(stomach docs—abbreviated ACG) disagrees with this and says you cannot actually diagnose GERD by looking inside the throat alone because what looks like inflammation to one doctor may not look like inflammation to another.
The ACG backs up their point by citing an interesting study where patients originally believed to have LPR(laryngopharyngeal reflux—basically upper throat reflux) were discovered to not actually have LPR at all:
That’s kind of serious. Another study the ACG mentions found that 86% of NORMAL people without GERD were said to show signs of GERD upon examination with a laryngoscope(which opens a whole can of worms I plan to cover in a future post).
By the way, here’s a picture of my laryngoscopy when I had acid reflux:
Do you see “inflammation”? My ENT at the time did, but apparently, the inflammation was minimal.
As for family docs?
Well, according to the American Academy of Otolaryngology themselves, prescribing PPIs without laryngoscopy to treat only hoarseness is “common among primary care clinicians.”
Did you get that? You don’t even need to test for GERD to get prescribed PPIs for life. This has been my experience and the experience of many readers as well.
ENT Doc vs. Family Doc vs. GI Doc—Who Should You See?
Which doctor do you see if you have GERD or suspect you have GERD? Well, in my opinion, it should be the GI doc, simply by virtue of specialty.
Family doctors are generalists who are trained to care for overall health.
ENTs are ear-nose-throat doctors who are trained to perform surgery on the face and neck. Their specialty is surgery. It’s in the logo:
But GI doctors, also known as gastroenterologists, specialize in the stomach, and as you probably know already, GERD is a disease of the stomach and lower esophagus. Therefore it follows that gastroenterologists will tend to be the most experienced and knowledgeable about acid reflux.
Case in point:
The American College of Gastroenterology is the only doctor’s association I know of, that due to widespread concern about the safety of long-term PPI use, released new guidelines last year on when and for how long a patient should be on PPIs.
Now, these new guidelines are really intended for clinicians, but if you are concerned about PPIs, it’s crucial for you to understand these guidelines as well.
So here’s the biggest takeaway from the updated guidelines regarding proper PPI use(print the quick guide here if short on time):
Different Types of GERD Call For Different Types of Treatment
It is generally agreed upon that there are 3 types of GERD. First, there’s typical GERD, which involves the symptoms of heartburn and regurgitation.
Then there’s atypical GERD which involves symptoms other than heartburn and regurgitation. So coughing, asthma, hoarseness, LPR, backpain, etc. are all classified as atypical symptoms(also called extraesophageal symptoms).
And then, there’s refractory GERD—acid reflux that does not get better despite PPI therapy.
Before we dive into the guidelines for each GERD type, it is important to note that a person is not limited to one type of GERD but can experience a combination thereof(I did).
Let’s begin with ACG guidelines for typical GERD, which is the most common:
1. Typical GERD
(a.) For patients who have heartburn and regurgitation but no alarm symptoms such as intense stomach pain or coughing up blood, an 8-week trial of PPIs once a day before their biggest meal is advised [typically dinner].
If the patient feels better after 8 weeks, then PPI use should be discontinued. It is presumed that suppressing stomach acid for the 8 weeks has allowed the patient’s esophagus to heal up.
If, however, the patient does not feel better after the 8-week trial, or if the patient’s symptoms come back after the 8-week trial, then a diagnostic endoscopy[stomach scope] should be performed after the patient has STOPPED PPIs for 2-4 weeks.
(b.) For patients who experience what’s called “alarm symptoms,” such as unexplained weight loss, GI bleeding, chest pain(unrelated to heart disease or heartburn), or if they just have poorer health in general, endoscopy and/or further reflux monitoring is recommended to see inside their stomach to make sure nothing sinister is going on.
(c.) If a patient does not have heartburn or regurgitation but for some reason the doctor suspects GERD, an endoscopy could be done to check, but if no evidence for GERD is found in the endoscopy, then it is recommended the patient come off PPIs if taking them.
Next, reflux monitoring should be performed with the patient OFF PPIs to find out if what the patient has is even acid reflux at all.
As a side note, it is not recommended to use a “barium swallow test” to diagnose GERD in a patient because it doesn’t test for reflux at all. All you see is how a patient swallows on x-ray. Technically, this tells us nothing about the acid reflux.
(d.) If a patient has LA grade C/D esophagitis or Barrett’s Esophagus, it is not recommended to perform reflux monitoring with the patient off PPIs to diagnose GERD[some patients have esophagitis. This type of patient should remain on PPIs.
This is because esophagitis patients who come off PPIs tend to experience even worse stomach inflammation, and fast.
2. Atypical GERD
If you’re diagnosed with atypical GERD—symptoms other than heartburn and regurgitation, here are ACG guidelines for treatment:
(a.) Carefully evaluate the patient for non-GERD causes because the lack of heartburn and regurgitation increases the chance the patient has something else other than GERD.
If a patient with extraesophageal symptoms but no heartburn or regurgitation is still suspected to have GERD, it is recommended that they undergo pH monitoring to confirm GERD before PPIs are prescribed. There has to be “objective” proof of reflux before PPI prescription.
(b.) For patients who experience extraesophageal symptoms and ALSO heartburn and regurgitation: twice-daily PPI therapy is recommended for 8-12 weeks to see if things get better before further testing is done.
(c.) Some things the ACG does not recommend: the ACG does not recommend doing an endoscopy to diagnose LPR, GERD-related asthma, or chronic cough [endoscopies are expensive. You generally need to be sedated and the chances of finding anything are low because of the lack of heartburn and regurgitation].
It is also not recommended to diagnose a patient with GERD/LPR, based on seeing how the vocal cords and throat look like with a laryngoscope. This is because multiple studies have shown laryngoscopy findings to be highly variable and subjective—same thing with pepsin testing[again we need sure evidence before potentially prescribing PPIs]. Other additional testing should be considered.
Regarding surgery for patients with atypical GERD/extraesophageal GERD symptoms, there must be objective evidence of reflux. Objective evidence is usually gathered via multiple GERD tests before surgery is recommended.
Remember, surgery involves rearranging anatomy. This comes with the risk of permanent side effects, therefore, surgery should not be recommended based on laryngoscopy findings alone.
3. Refractory GERD
Refractory GERD is GERD that does not respond to PPI medication. The guidelines for refractory GERD are:
(a.) PPI therapy optimization. Make sure the patient is taking their PPIs consistently every day, 30 minutes before their meals. Also, would increasing PPI dosage help?
(b.) If PPI optimization still doesn’t work, impedance-pH monitoring is recommended. For patients who HAVE NOT had a previous pH test or endoscopy confirming LA Grade C/D esophagitis and/or long-segment Barrett’s Esophagus, note that the pH test should be done with the patient OFF PPIs.
IMPORTANT: If the impedance-pH monitoring test comes back normal, PPI THERAPY SHOULD STOP unless there is another strong indication for continuing back on PPIs.
Also, if the patient has not had an endoscopy at this point, a diagnostic upper endoscopy is recommended(the patient should be off of PPIs for 2-4 weeks in advance).
Now, for patients who’ve already had an established diagnosis of GERD but are not responding well to twice-a-day PPI therapy, an esophageal impedance-pH monitoring test is still recommended to see what’s going on inside. In this case, the patient should still be ON PPIs to ensure test accuracy.
*If the pH monitoring and/or endoscopy comes back normal in any case, then a high-resolution esophageal manometry can be considered to further study why the patient isn’t responding to PPIs. It’s you and your doctor’s call.
(c.) For patients who experience regurgitation as their main symptom and have an established diagnosis of GERD via endoscopy and/or pH monitoring, anti-reflux surgery can be considered. As mentioned, the attending physician may also want to perform an esophageal manometry for a deeper, final evaluation before recommending surgery.
Intensive and More Expensive, but More Objective
If the doctor that you saw for your reflux was anything like mine, they probably didn’t follow any of these guidelines but instead just prescribed you PPIs straight away. I can see why now. The tests are expensive and uncomfortable.
So maybe my doc just wanted to save me time, trouble, and money? Still, I would have liked to make that decision myself. Could I have been spared years of suffering if I had just gotten the right tests done? I may never know for sure.
That’s why it’s so important to see the right doctor.
Remember, gastroenterologists specialize in diseases of the stomach. They are the people who actually have access to the diagnostic tools needed to objectively confirm you have GERD before prescribing you PPIs.
So, if I could do it all over again, I would go straight to a gastroenterologist instead of the ENT who told me to take PPIs FOREVER(without ANY further testing by the way).
I know this can be challenging because different healthcare systems may have different procedures, but if possible, consider seeing a gastroenterologist directly. If it’s difficult for you to get a referral, then at least print this guide out to show your doctor and make sure they know what they’re doing.
DID YOU KNOW…
The adherence to association guidelines among gastroenterologists and ENTs is about 58% and 56% respectively? Turns out, doctors are human too(specialists included), which is why you should print out this guide to remind them to stick to proper ACG guidelines:
Roumans, C., van der Bogt, R. D., Steyerberg, E. W., Rizopoulos, D., Lansdorp-Vogelaar, I., Sharma, P., Spaander, M., & Bruno, M. J. (2020). Adherence to recommendations of Barrett’s esophagus surveillance guidelines: a systematic review and meta-analysis.
Kobayashi, K., Sekiya, N., Ainoda, Y., Kurai, H., & Imamura, A. (2017). Adherence to clinical practice guidelines for the management of Clostridium difficile infection in Japan: a multicenter retrospective study.
Final Thoughts: Are Pharmaceutical Companies More Powerful Than Doctors?
It seems like it because PPIs have been an over-the-counter(OTC) medication since 2003, and continues to be an over-the-counter medication today.
So technically, anyone can walk into their local drug store and pick up a box of PPIs with no doctor’s prescription at all.
And they are:
A 2014 study of GERD patients done by Sheikh et al. from Metro Health Medical Center in Cleveland, Ohio observed that 32% of surveyed patients purchased PPIs from a drugstore. So low adherence to PPI guidelines makes sense. Patients can just buy PPIs at any drugstore—no doctor needed.
Also, keep in mind that pharmaceutical companies advertise to patients. We’ve all undoubtedly seen commercials for a certain purple pill company on the tv, the internet, Costco, and more. So why bother?
And that’s the dilemma. Even though we know taking PPIs long-term and/or unnecessarily could potentially increase the risk of disease and death, there’s little we can do about it because of the enormous power these pharmaceutical companies wield. I mean they literally spend millions of dollars a year lobbying the US government. It’s simply too much for a busy doctor to take on by themselves.
I think the motives are kind of murky, but let’s just give that certain pharmaceutical company the benefit of doubt for a minute. Maybe they’re just not aware that consumers buy their drugs direct…which is why they’re running ads directly to consumers?
Maybe they’re just unaware of long-term PPI risks even though they’re getting sued like crazy for negative side effects?
Unlikely. But I’ll tell you what I think our doctors can do to improve patient safety. First, they can find better, safer ways to diagnose and test for GERD. For example, instead of having a patient go on PPIs for 8 weeks, they can have the patient go plant-based for 8 weeks instead.
Why plant-based you ask?
Well, studies actually show that a diet high in saturated fat, high in cholesterol, and low in fiber is linked with GERD. A plant-based diet, on the other hand, is linked with less inflammation and less acid reflux.
Second of all, doctors can advocate for PPIs to be removed from the consumer market. What if we just went back to the days when you had to have a written prescription to get PPIs? I think this, along with more outreach, could lower the rate of PPI misprescription substantially.
Isn’t that the goal?