At a glance
- PPIs are safe for most people. Use the lowest dose that controls your symptoms.
- Some people should stay on a PPI, such as people with Barrett's esophagus, severe esophagitis or a past bleeding ulcer.
- If you take a PPI for heartburn and feel well, ask your doctor if you could take a lower dose, or take it only when you need it.
- Don't stop a PPI that was prescribed for a serious reason without talking to your doctor.
- When you cut back, heartburn may flare for a while. Antacids, Gaviscon or famotidine (Pepcid AC) can help.
- Zantac is no longer sold in Canada. Don't use old packages.
- If you also take a water pill or digoxin, ask about a magnesium blood test.
- Call your doctor if you get diarrhea that doesn't get better while on a PPI.
What are PPIs?
Proton pump inhibitors (PPIs) are pills that turn down how much acid your stomach makes. They are the strongest acid blockers. They treat heartburn, heal sores in the food pipe and stomach, and protect the stomach in some people.
| Medicine | Common brand names in Canada |
|---|---|
| omeprazole | Losec |
| esomeprazole | Nexium, Nexium 24HR (no prescription needed) |
| pantoprazole | Pantoloc, Tecta |
| lansoprazole | Prevacid |
| rabeprazole | Pariet |
| dexlansoprazole | Dexilant |
How to take it: swallow it 30 to 60 minutes before a meal, usually breakfast. PPIs work best when food comes soon after the pill.
Who needs a PPI for the long term?
For some people, a PPI prevents real harm. Your doctor will likely advise you to keep taking it if you have:
- Barrett’s esophagus, a change in the lining of the food pipe caused by long-term reflux
- Severe esophagitis, which means deep sores in the food pipe seen on a scope test
- A narrowing (stricture) of the food pipe caused by acid
- Eosinophilic esophagitis, an allergy-type swelling of the food pipe
- A past bleeding ulcer, or a high chance of bleeding from the stomach. For example, you take anti-inflammatory pain pills (NSAIDs) such as ibuprofen or naproxen and have other risks your doctor has found.
If one of these applies to you, don’t stop your PPI on your own. Talk to your doctor first.
Does a PPI protect me if I take aspirin or a blood thinner?
It depends on your own risk. In a large study called COMPASS, people taking low-dose aspirin or a blood thinner were given pantoprazole or a dummy pill. Pantoprazole did not lower stomach and bowel problems overall. It may have lowered bleeding from the stomach, but only a small number of people benefited. Your doctor will decide if you are at high enough risk to need one.
Could I take less, or stop?
Experts advise that everyone on a PPI should have a regular check of why they take it. If you took a PPI for at least 4 weeks for heartburn or mild sores in the food pipe, and you feel well now, you may be able to:
- Take a lower dose, for example half the dose or once a day instead of twice, or
- Stop and take it only when needed, every day until your symptoms go away, then stop again
Both choices work. Pick the one that suits you best, with your doctor or pharmacist. You can cut down slowly or stop all at once. No one way has been shown to be better.
Ranitidine (Zantac) used to be a common choice. Zantac is no longer sold in Canada. In 2019, Health Canada asked companies to stop selling ranitidine because some of it contained an unwanted chemical called NDMA. A few ranitidine products have come back since then, but only if every batch is tested. Famotidine (Pepcid AC) is a similar medicine that you can buy without a prescription.
What about the risks in the news?
You may have read that PPIs are linked to dementia, kidney disease, broken bones, pneumonia or heart attacks. Most of these worries come from studies that only watched people who took PPIs. People who take PPIs are often older and have more health problems to start with. Those other problems, not the PPI, may explain the link.
A stronger kind of study picks people by chance to take a PPI or a dummy pill. The largest one, COMPASS, included 17,598 adults with heart or blood vessel disease. They took pantoprazole or a dummy pill for about 3 years.
| Problem | What COMPASS found |
|---|---|
| Dementia, kidney disease, broken bones, pneumonia | No real difference between the two groups |
| Heart attack, stroke, cancer, death from any cause | No real difference |
| Gut infections | A little more common: 1.4 in 100 people on pantoprazole, compared with 1.0 in 100 on the dummy pill |
People in COMPASS were around 68 years old on average. The study lasted about 3 years, so we know less about use for 10 years or more. Still, the results are reassuring.
The main reason to stop a PPI is that you no longer need it, not fear of side effects.
Side effects to know about
- Common, mild side effects: headache, nausea, belly pain, diarrhea, constipation or gas. These often settle.
- Low magnesium. This is uncommon. It most often happens after a year or more of use, and it gets better when the PPI is stopped. Signs include muscle spasms or twitching, an uneven heartbeat, or seizures. If you also take a water pill (diuretic) or digoxin, ask your doctor about a magnesium blood test.
- Gut infections, including C. difficile. Stomach acid helps kill germs, so gut infections are a little more likely on a PPI. C. difficile is a germ that causes watery diarrhea. Call your doctor if you have diarrhea that doesn’t get better.
You don’t need routine blood tests or bone scans just because you take a PPI. Your doctor will order them if you have other reasons.
Questions to ask at your next visit
Bring these questions to your doctor or pharmacist
- Why am I taking this PPI, and do I still need it?
- Am I on the lowest dose that works for me?
- Could I take it only when I need it?
- If I cut back, what should I do if heartburn comes back?
Sources for this guide
Sources
- Moayyedi P, Eikelboom JW, Bosch J, et al. Safety of proton pump inhibitors based on a large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin (COMPASS). Gastroenterology 2019;157:682–691. PMID 31152740 17,598 people (mean age 67.6) with heart or artery disease; pantoprazole 40 mg vs placebo for a median of 3.01 years. No difference in any outcome except enteric infections (1.4% vs 1.0%; OR 1.33, 95% CI 1.01–1.75). C. difficile about twice as common but only 13 events (not significant).
- Moayyedi P, Eikelboom JW, Bosch J, et al. Pantoprazole to prevent gastroduodenal events in patients receiving rivaroxaban and/or aspirin in a randomized, double-blind, placebo-controlled trial. Gastroenterology 2019;157:403–412. PMID 31054846 Routine pantoprazole did not reduce upper GI events overall (HR 0.88, 0.67–1.15) but may reduce bleeding from gastroduodenal lesions (HR 0.52, 0.28–0.94).
- Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician 2017;63:354–364. PMID 28500192 Canadian guideline: after at least 4 weeks for heartburn or mild–moderate esophagitis with symptoms resolved, lower the dose or stop and use on demand. Not for Barrett's, LA grade C/D esophagitis or a past bleeding ulcer.
- Deprescribing.org. Proton pump inhibitor (PPI) deprescribing algorithm. Bruyère Research Institute, 2018. Lower dose or stop and use on demand; monitor at 4 and 12 weeks; if symptoms last 3–7 days and interfere with life, consider returning to the previous dose.
- Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology 2022;162:1334–1342. PMID 35183361 Review the reason for a PPI regularly; don't deprescribe in complicated GERD, Barrett's, eosinophilic esophagitis or high bleeding risk; taper or abrupt stop both acceptable; decide on indication, not fear of side effects.
- Freedberg DE, Kim LS, Yang YX. The risks and benefits of long-term use of proton pump inhibitors: expert review and best practice advice from the American Gastroenterological Association. Gastroenterology 2017;152:706–715. PMID 28257716 Long-term PPI for Barrett's and for people at high risk of NSAID ulcer bleeding; no routine monitoring of bone density, creatinine, magnesium or B12.
- Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022;117:27–56. PMID 34807007 PPI 30–60 min before a meal; lifelong PPI for LA grade C/D esophagitis; COMPASS shows most observational associations were confounding; common minor side effects.
- Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022;117:559–587. PMID 35354777 At least once-daily PPI in Barrett's esophagus.
- Wani S, Zhou MJ, Sawas T, et al. AGA Clinical Practice Guideline on Surveillance of Barrett's Esophagus. Gastroenterology 2025;169:1184–1231. Endorsed by the Canadian Association of Gastroenterology. PMID 41125322 Conditional recommendation for daily PPI therapy (vs no therapy, and vs antireflux surgery) to prevent progression in Barrett's esophagus.
- Health Canada. Ranitidine products recalled because of a nitrosamine impurity (2019–2022) and Status of ranitidine drugs in Canada (2020). September 2019: companies asked to stop distributing ranitidine while NDMA was assessed; Zantac recalled October 2019. Companies may resume sales only if they test every batch before release and retest through shelf life (page last updated March 2022). Drug Product Database (checked 11 October 2026): all Zantac products cancelled; a few generic ranitidine products (e.g. Mint-Ranitidine, Rx; Pharmascience Maximum Strength Acid Reducer, non-prescription) listed as marketed.
- Health Canada. Proton pump inhibitors: hypomagnesemia accompanied by hypocalcemia and hypokalemia. Canadian Adverse Reaction Newsletter 2011;21(3). Low magnesium suspected with PPI use of 1 year or more; reversible.
- Pantoloc (pantoprazole) Canadian product monograph. Takeda Canada, 2020. Consider checking magnesium before and during long-term use, or with digoxin or diuretics; consider C. difficile in diarrhea that does not improve.
- Vaezi MF, Yang YX, Howden CW. Complications of proton pump inhibitor therapy. Gastroenterology 2017;153:35–48. PMID 28528705 Evidence does not establish that PPIs cause most reported harms; confounding explains much of the concern.
This guide is for general education. It can't replace advice from your own care team, who know your health history.