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The Risks and Benefits of Long-term Use of Proton Pump Inhibitors CPU Patient Companion

Clinical Practice Updates are developed under the guidance of the AGA Institute Clinical Practice Updates Committee and provide best practice advice on cutting-edge topics in the practice of gastroenterology and hepatology. The Clinical Practice Updates are based on a combination of a review of the current scientific literature and expert opinion to help guide gastroenterologists and other health-care professionals at the point of care. The below information presents important content from AGA Clinical Practice Updates in a way that will help patients better understand AGA’s best practice advice on these new, hot-button topics.

AGA Clinical Practice Update: The Risks and Benefits of Long-term Use of Proton Pump InhibitorsThe information provided by the AGA Institute is not medical advice and should not be considered a replacement for seeing a medical professional.

What are proton pump inhibitors?

  • Proton pump inhibitors (PPIs) are drugs that are used to lessen the amount of acid made in the stomach.
  • PPIs are used to help calm symptoms of heartburn and other symptoms that result from gastroesophageal reflux disease (GERD).
  • They are also helpful in treating open sores (ulcers) found in the lining of the stomach or intestine (stomach ulcers).

What are the potential risks of long-term PPI use?

  • Many negative findings have been linked with the long-term use of PPIs, such as:
    • Kidney disease
    • Dementia
    • Fractures
    • Infections
    • Vitamin/mineral deficiencies.
  • Some of these studies have been widely publicized in the popular press. However, the quality of evidence supporting these findings is low to very low.
  • Further, the odds of these events occurring is very low, less than 1% per patient per year in excess risk over patients not taking PPIs.
  • Infections
    • Small intestinal bacterial overgrowth (SIBO)
      • SIBO is when a large number of bacteria are found in the small intestine, causing bloating and pain, diarrhea (loose stool) and vitamin deficiencies.
      • The use of PPIs raises the chance of getting more bacteria into the intestine.
    • Non-typhoidal Salmonella and Campylobacter
      • Non-typhoidal salmonella is an infection that causes:
        • gastroenteritis (stomach flu).
        • bacteria in the blood.
        • bacterial infections that are found in a specific part of the body (known as focal infection).
      • Campylobacter is an infection that is found in the small intestine from a type of bacteria called Campylobacter jejuni, and is a type of food poisoning.
    • Clostridium difficile infection 
      • Clostridium difficile infection (also known as C. diff) is a type of bacteria that can cause severe inflammation of the large intestine.
      • It can cause severe diarrhea and belly pain.
      • It most often occurs after taking some antibiotics but may also happen with taking PPIs.
    • Pneumonia
      • Pneumonia is a lung infection due to bacteria, viruses or breathing toxic fumes causing the air sacs of the lungs to fill up with fluid or pus.
  • Micronutrient deficiencies
    • Micronutrient deficiencies are a lack of vitamins and minerals that the body needs to stay healthy.
    • Micronutrient deficiencies that have been linked with PPI use:
      • Calcium
      • Iron
      • Magnesium
      • Vitamin B12
  • Kidney disease
    • There may be an increased chance of immediate or chronic kidney disease with use of PPIs.
    • For patient taking PPIs long-term, your doctor may want to do a yearly blood test to check on the health of your kidneys.
  • Osteoporosis
    • PPIs may interfere with absorption of calcium.
    • With this, there is some worry that use of PPIs for years may raise the risk of osteoporosis.
    • If you have or are at increased risk for osteoporosis, you may want to talk about it with your doctor.

Treatment of gastroesophageal reflux disease (GERD)

  • Short-term use of PPIs is very helpful in treating symptoms of GERD.
  • Uncomplicated versus complicated GERD
    • Uncomplicated GERD is a set of symptoms, such as heartburn, acid reflux, and nausea alone.
    • Complicated GERD is when patients have symptoms that happen along with severe damage to the lining of the esophagus by the stomach acid These may include:
      • Problems within the esophagus, such as signs of ulcers or Barrett’s esophagus (abnormal cell growth).
      • Complications outside of the esophagus, such as inflammation and infection of the lungs, asthma, chronic coughing and chest pain.
  • Long-term use of PPIs in complicated GERD is needed to stop esophagitis (irritation or swelling of the esophagus) from coming back.
  • There is less certainty for the success of long-term PPI use in patients with uncomplicated GERD.
  • To stop the possible risks of long-term PPI use, patients with uncomplicated GERD may be able to cut their dose from twice to once-daily usage.
  • For patients with complicated GERD, the benefits of long-term PPI use likely outweigh the risks.

Always make sure to talk about your concerns with your doctor before making any changes to your medications or dose.


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