Algorithm for reviewing patients using PPIs for GORD, stepping down or stopping PPIs when appropriate 

This algorithm is used for patients with gastro-oesophageal reflux disease (GORD) who are taking a proton pump inhibitor (PPI).

Return to the algorithm on the resources page for PPIs

It has two major components, which are shown on either the left or the right side of the algorithm.

On the left side, the algorithm addresses patients with well-controlled GORD symptoms.

On the right side, the algorithm addresses patients with GORD symptoms that are not well controlled.

Starting at the top of the algorithm, there are two groups of patients. One group has been on an initial PPI for 4 to 8 weeks for suspected GORD. The other group has been on a PPI long term for confirmed GORD.

Both of these patient groups feed into a box titled ‘Review patient on PPI’.

The algorithm then splits into two components, depending on whether symptoms are well controlled or not.

If GORD symptoms are well controlled, an arrow leads to a box titled ‘Discuss options and implement stepping down to lowest effective dose, or stopping’. 

Within the box titled ‘Discuss options and implement stepping down to lowest effective dose, or stopping’ there are three hexagons that are interconnected with two-way arrows.

From left to right, these hexagons are labelled ‘Use lower dose/frequency of PPI regularly’, ‘Use PPI on demand (as required)’ and ‘Stop PPI’.

If symptoms are well controlled for 4 to 8 weeks, the arrows are followed to the right.

If symptoms are not well controlled, the arrows are followed to the left.

Beneath these three hexagons, there is a note to ‘Manage rebound acid hypersecretion as required’. The recommendations for this note are to ‘Gradually reduce the dose before stopping PPI to reduce risk’ and ‘Treat mild rebound symptoms with antacids or H₂ receptor antagonists’.

Moving back up to the box titled ‘Review patient on PPI’, if GORD symptoms are not well controlled, an arrow leads to a box advising to ‘Confirm adherence’ and ‘Consider endoscopy (+/– referral to specialist)’. This then splits into two possible directions.

If endoscopy indicates another diagnosis, an arrow leads to a box that advises ‘Manage new diagnosis appropriately’.

If endoscopy supports complex GORD diagnosis, an arrow leads to a box that advises ‘Consider stepping up treatment to twice-daily standard dose or high dose PPI’.

There are three footnotes that accompany this box.

• Footnote a explains that complex GORD is GORD requiring more than once-daily standard dose PPI therapy to manage symptoms.
• Footnote b explains that the initial prescription of twice-daily standard dose PPI must be made by, or in consultation with a specialist. An additional note states that ongoing twice-daily standard PPI may be prescribed by a specialist or a GP.
• Footnote c explains that high dose PPI for complex GORD is restricted to prescription by a specialist.

The 'Consider stepping up treatment box' leads via an arrow to a box advising 'Review patient after 4 to 8 weeks' and 'Confirm adherence'. This then splits into two possible directions.

If the symptoms are well controlled after 4 to 8 weeks with a twice-daily standard dose or high dose PPI the 'Review patient after 4 to 8 weeks and 'Confirm adherence' box leads via a dashed arrow to the ‘Discuss options and implement stepping down to lowest effective dose, or stopping’ box.

If symptoms are not well controlled after 4 to 8 weeks with a twice-daily standard dose or high dose PPI, an arrow leads to a box advising 'Refer to specialist'

An additional note states 'If high dose therapy is required for symptom control, the standard dose given twice daily is more effective than a high dose (esomeprazole 40 mg) given once daily.

Return to the algorithm on the resources page for PPIs