Omeprazole: Do You Still Need It? | Dr Dan Reardon

Omeprazole. Do you still need it?

Omeprazole was designed for a few weeks and is taken for years. This page is what I, Dr Dan Reardon, consider when someone on it, or on lansoprazole or another acid blocker, sits opposite me in Sutton Coldfield.

Around 36 million prescriptions a year in England, the fourth most prescribed medicine in the country; lansoprazole is the third

In an English study of 77,000 people on a proton pump inhibitor continuously, 62% had no recorded reason for it

Stopping dead usually fails, and the heartburn that follows is often the drug, not the disease

Started for weeks. Taken for years.

Omeprazole and its relatives (lansoprazole, esomeprazole, pantoprazole) are good medicines. They heal ulcers, settle reflux, and protect the stomach of someone who needs aspirin or an anti-inflammatory. They were designed for short, defined courses, and used that way they are among the safest drugs we have.

The problem is not the drug. It is that the course never ends. It was started in hospital, or for an ulcer that healed, or alongside a painkiller that has since stopped, and it has been on the repeat ever since. There are guidelines for when to start a proton pump inhibitor. There is almost no structured habit of deciding when the reason to continue has gone.

The institution made a decision to start. Nobody made a plan to stop. That sentence describes more medicines than this one, but omeprazole is where it is most true.

The four questions, asked of omeprazole.

Why was it started?

An ulcer. Reflux. Protection of the stomach lining while you took aspirin, an anti-inflammatory or a steroid. A hospital admission where it was added routinely and never taken off. These are different reasons with different answers, and in a majority of long-term users the reason is not written down anywhere.

What I want to see: the original reason, in writing, and whether anyone has ever had a camera look at your stomach.

Is the problem it treated still there?

This is the question that matters most for this medicine, and it is not the same as "do you still get heartburn". If the omeprazole was started for an ulcer caused by a bacterium that was then treated and cleared, the original problem no longer exists, full stop. Any indigestion you have today is a new question, not proof that the old one is still there. Most reviews never separate the two.

What I want to see: your records for the thing that started it, and whether that thing was ever confirmed to have gone.

Has your physiology changed since?

Weight lost. Alcohol down. A different diet. The anti-inflammatory you were being protected from, stopped two years ago. The body that needed acid suppression and the body sitting in front of me may not be the same body. Long-term acid suppression also changes things in its own right: it can lower vitamin B12 and magnesium, which is why those are worth checking before anything changes.

What I want to see: what has changed since it was started, and a baseline set of bloods before we touch it.

Is one medicine treating another's side effect?

Two versions of this. The first is the omeprazole that was added to cover a painkiller and outlived it. The second is subtler: you tried to stop, the heartburn came roaring back, and the omeprazole was restarted as proof you needed it. The roar was the drug's own rebound. The restart treated a side effect of stopping as if it were the disease, and the trap closed.

If you have tried to stop omeprazole before and it went badly within a couple of weeks, I would like to hear exactly what happened and when.

What stopping omeprazole involves.

After months or years of acid suppression, the stomach adapts. Remove the drug suddenly and it makes more acid than it did before you started. This is not a theory. In a trial of 120 healthy volunteers with no acid problem at all, nearly half developed heartburn or indigestion in the weeks after eight weeks of a proton pump inhibitor was withdrawn, against about one in seven on placebo. People with nothing wrong with them got reflux the drug had created.

That is why stopping dead fails for most people, and why a short taper is little better. What works for most is a planned step-down to an as-needed endpoint, with something in hand for the symptoms before the first dose comes down, and a clear understanding of what the first few weeks will feel like and why. Symptoms soon after stopping are usually rebound. Symptoms that persist well beyond that window are more likely the original problem. Timing is how the two are told apart, and that distinction is the whole skill.

How long the step-down takes, and how it is paced, depends on why you were taking it and on a few things I can measure before we start. That is written into your plan, for you. Never stop or change this medicine without talking to a doctor.

When omeprazole should stay.

Barrett's oesophagus, confirmed on biopsy. Acid suppression is lifelong treatment, not symptom relief.

Severe inflammation of the oesophagus seen on camera, including after it has healed, or a narrowing caused by reflux.

A history of a bleeding ulcer, or a recent bleed from the stomach or gullet.

Ongoing protection you still need: aspirin or blood thinners with a high bleeding risk, long-term anti-inflammatories, certain steroid combinations.

Rarer conditions where the drug is active treatment, such as an acid-producing tumour or an allergic inflammation of the oesophagus that responds to it.

If any of these is you, the plan says so and says why, and the omeprazole stays. The review is not a campaign against the drug.

What the review does for someone on omeprazole.

I am Dr Dan Reardon, an NHS A&E doctor, GMC 6098984, and a CQC-registered independent doctor provider. In private practice I do one thing: the Independent Medication Review, in person at Sutton Medical Consulting in Sutton Coldfield.

For someone on omeprazole, I go back to the reason it was started and find out whether that reason still exists. I look at what else is on your list, because the answer often depends on it. I arrange the bloods that should be checked before anything changes. Then I write your plan: whether it stays, and why; or how it comes down, what to have in hand, what the first weeks will feel like, and the point at which a symptom stops being rebound and becomes something to look at. If you want me alongside you while you carry that out, that is what supervised step-down is for.

Sometimes the answer is that you need it, and you leave knowing that for certain. That is worth having too.

MB ChB · BSc · MSc Mental Health · GMC 6098984 · CQC registered

Questions people ask about omeprazole.

Can I just stop taking omeprazole?

Not dead, and not without a doctor. After months or years on a proton pump inhibitor the stomach makes more acid than before once the drug is removed, so stopping abruptly fails for most people. A planned step-down with something in hand for the symptoms works for most, but whether you should stop at all depends on why it was started and whether that reason still exists.

Why did my heartburn come back when I stopped omeprazole?

Often because of the drug, not the disease. In a trial of healthy volunteers with no acid problem at all, nearly half developed heartburn or indigestion in the weeks after eight weeks of a proton pump inhibitor was withdrawn, against about one in seven on placebo. Symptoms soon after stopping are usually rebound; symptoms that persist well beyond that window are more likely the original problem. Timing is how a doctor tells them apart.

Is long-term omeprazole harmful?

It is a low-toxicity medicine and the case for reviewing it does not rest on it being dangerous. Long-term use can lower vitamin B12 and magnesium and slightly raises the risk of some gut infections; other reported links are unproven. In someone with a real ongoing reason the benefit outweighs all of that. In someone whose reason has gone, they are carrying the risk for none of the benefit. That is the argument, not fear of the drug.

I take lansoprazole, not omeprazole. Does this apply?

Yes. Lansoprazole, esomeprazole, pantoprazole and rabeprazole are the same family and the same questions apply. The doses and the step-down differ by drug, which is one of the reasons the plan is written for you rather than copied from a page.