Recommendations for acid suppressant use
As always, the decision about whether, when, and how to modify PPIs dosing should be based on a thoughtful assessment of the risk-benefit ratio for individual patients. Therefore, patients should not immediately stop their PPIs as there are many important reasons to be on a PPI. Patients are encouraged to discuss the benefits and risks of continuing PPIs with their doctor before making any treatment changes. As with any medication, the lowest effective dose should be used, when clinically indicated, for the shortest possible time.
The main result of the study by Almario et al., was that use of PPIs, particularly twice-daily PPIs, appears to increase the risk of COVID-19. Clinicians should carefully consider whether twice-daily PPI dosing is necessary for their patients. This is particularly important for those who are vulnerable to severe COVID-19 infection (e.g., the elderly and those with co-morbidities). Twice-daily PPI use can lead to 24-hour median intragastric pH >6 and sustain pH >4 for more than 20 hours (24-26). Moreover, previous studies suggest that twice-daily PPI does not offer clinically meaningful benefits over once-daily dosing for GORD. Although some patients may undoubtedly benefit from twice-daily dosing, it is always useful to re-evaluate the need for high-dose PPIs, particularly when the population prevalence of COVID-19 remains high.
The other thing to consider is that the above studies did not find an increased risk for COVID-19 among those who use H2RAs, and one study revealed its role in reducing clinical deterioration of COVID-19 infection. Therefore, H2RAs may be considered as an alternative for PPIs in treatment for acid-related conditions during the present pandemic.
For patients who need to continue a PPI for an appropriate reason, it is essential to emphasise the best ways to reduce the risk of getting COVID-19: regular hand washing, social distancing and wearing a mask when around others.