Can you safely taper off a proton pump inhibitor if reflux symptoms improve?

Q. I have had acid reflux off and on in the past, but it has been much better recently. About one year ago, a doctor looked down my esophagus and into my stomach (a test he called an upper endoscopy). My esophagus was inflamed and I was told to take pantoprazole indefinitely. I rarely have heartburn anymore and never need antacids. I certainly don't want to take this medicine forever. If I eat less acidic foods and don't experience heartburn, is it necessary to take this drug to keep my esophagus healthy?

A. Pantoprazole (Protonix) is a proton pump inhibitor. Drugs in this class are the most potent acid inhibitors. Other proton pump inhibitors include omeprazole (Prilosec), esomeprazole (Nexium), rabeprazole (Aciphex), lansoprazole (Protonix), and dexlansoprazole (Dexilant).

There is no simple yes or no answer to your question, but here is how I approach this very common situation.

My recommendation depends on some details about your reflux symptoms that I don't have. Was the heartburn present for a long time before you had the endoscopy? Were you taking the pantoprazole or another daily stomach acid blocker for many weeks when you had the endoscopy?

The reason for these questions is to get a better picture of the severity of your esophageal inflammation (esophagitis). If your reflux was severe or you had been on treatment for a few weeks prior to the endoscopy, I would likely recommend continuing acid blocker therapy for a prolonged period of time.

If the inflammation was severe, then prolonged therapy with a proton pump inhibitor, such as pantoprazole, is warranted. Treating esophagitis is not just about controlling symptoms. Persistent severe inflammation of the esophagus from acid reflux can lead to scarring and narrowing of the lower esophagus. It also increases your risk of developing a condition called Barrett's esophagus, which can lead to cancer.

Unless a person has persistent esophagitis, treatment for acid reflux can step down to less potent anti-acid medications. If you and your doctor decide it's the right time to make a change from pantoprazole, you will want to wean yourself off the medication. You don't want to just stop it abruptly because you would likely get rebound heartburn; your body is used to the acid blocker.

If you were originally told to take pantoprazole (or another proton pump inhibitor) twice a day, I would likely suggest decreasing it to once per day. If you already take it once per day, you might take it every other day instead. On the "off" days, use an H2 blocker or antacids. Continue to slowly taper the medications.

Losing weight, not lying down after eating, and avoiding foods that typically cause your heartburn will often help.

Assuming the heartburn does not return when you taper off the proton pump inhibitor, you and your doctor can decide if another endoscopy is warranted to make sure the esophagitis has healed.

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