It is confirmed that Ajit is not taking an over-the-counter NSAID or aspirin and does not have a health condition to warrant ongoing PPI use.
Recognising that abrupt cessation of a PPI can cause rebound hypersecretion of gastric acid, leading some people to believe they still need a PPI, this is discussed with Ajit. He opts to trial a decrease in omeprazole dose to 10mg twice daily as he is used to taking this medicine twice daily.
It is essential that the aim is PPI cessation, so allowing Ajit this level of control can be helpful. For instance, if he becomes symptomatic, he could use omeprazole 30mg daily for a short time. It is raised with him that going to once-daily dosing will be the next step. After that, it could be alternate days or on an as-required basis.
Ajit has medical insurance and is not concerned about medication costs. Therefore, a potential consideration is parenteral iron replacement using ferric carboxymaltose or iron polymaltose, but Ajit does not like the idea of an infusion and chooses to remain on oral iron.
A 2019 Goodfellow Gem (https://bit.ly/2OK0Gwy) gives confidence to advocate for alternate-day dosing of ferrous sulphate with potentially fewer adverse effects and a likely lower impact on levothyroxine.
Generally, the advice is for levothyroxine to be taken on an empty stomach with a glass of water in the morning, at least half an hour before food. For Ajit, this is more problematic – with his twice-daily dosing of omeprazole (optimal dosing), the PPI is also given first thing in the morning before breakfast.
This problem is discussed with Ajit. As an interim measure, he agrees to take the levothyroxine an hour before lunch and, while not perfect, to trial taking the iron supplement at night on alternate nights, recognising he will soon be dropping the night-time dose of his omeprazole. Ajit has no phone to record or remind him of his medicines administration, so he uses a small notebook to do this.
Given the omeprazole and iron dosing will be altered, Ajit’s thyroid function should be monitored monthly while the PPI is ceased, and hopefully the iron after that. If any thyroid dysfunction symptoms do appear, he should return to see you earlier.
Leanne Te Karu is a pharmacist prescriber working in primary care; Professor Bruce Arroll is a GP and head of department of general practice and primary health care at the University of Auckland