Proton pump inhibitors include the following commonly prescribed medications, the most inexpensive over-the-counter nonprescription forms of which are shown in bold below:
Omeprazole 20 mg (Prilosec® OTC and multiple generic store brands)
available without prescription
least expensive treatment option
Prilosec® (omeprazole)
Omeprazole
available as generic
Prevacid® (lansoprazole)
Lansoprazole
generic available November 2009
Prevacid 24H® (lansoprazole)
approved by FDA for nonprescription sale in May 2009
Aciphex® (rabeprazole)
Protonix® (pantoprazole)
available as generic
Nexium® (esomeprazole)
Dexilant® formerly Kapidex®(dexlansoprazole)
PPIs are frequently recommended for the acute and long-term management of gastroesophageal reflux disease (GERD). These drugs are quite safe and well tolerated, effective in controlling symptoms, and effective in healing and keeping healed the acid-related inflammation (erosive esophagitis) that can lead to serious complications. They also vary widely in cost. Serious side effects are unusual.
Several studies have recently shown an increased risk for hip fracture in association with the chronic use of these medications, and physicians may recommend the use of calcium with vitamin D, particularly in the form of calcium citrate (Citracal®) in patients needing to take these medications long term. Other risks associated with the use of PPIs may include an increased risk for certain infections (community-acquired pneumonia, Clostridium difficile infection), and effects related to chronic low stomach acid and its effects on the absorption of some nutrients and on certain gut hormones such as gastrin.
Recent studies show that combining a PPI with the anti-platelet drug Plavix® (clopidogrel) may decrease the effectiveness of the anti-platelet drug in some patients, though the clinical effect of this interaction appears to be minimal, based on the most current information.
When first reported, the potential for PPIs to reduce anti-platelet drug effectiveness concerned physicians because of the possibility of an associated increase in the risk of clot related events such as stroke, recurrent heart attack or clot formation within a coronary stent. Patients for whom both PPI therapy and anti-platelet treatment with Plavix (clopidogrel) is indicated may have been asked to take their medication at different times of day (to decrease the potential for an adverse drug-drug interaction), or to switch to a different PPI, or to discontinue PPI therapy (often substituting a less potent type of acid inhibiting medication known as an H2-blocker), based on the estimated relative risks in their own case. H2-blockers, also known as H2-antagonists, include the following medications, which are available in prescription and nonprescription strengths: Tagamet® (cimetidine), Zantac® (ranitidine), Pepcid® (famotidine) and Axid® (nizatadine).
Specialists in the fields of gastroenterology and cardiology have been monitoring research developments in this area closely. In November of 2008 the American College of Gastroenterology (ACG), American Heart Association (AGA) and the American College of Cardiology (ACC) issued a joint statement after evaluating data presented at the ACC Meeting. At the time, these groups interpreted the strength of evidence in the available studies of PPIs and Plavix as being insufficient to cause a change in clinical practice. The AHA/ACC and the American College of Gastroenterology recommended that patients who were taking these medications should not change their medication regimen unless advised by their health care provider.
Since then, there has been evidence published suggesting that the interaction between Plavix® (clopidogrel) and PPIs may be less of a problem, or may not occur, with the PPI Protonix® (pantoprazole), which is not metabolized through the P450 2C19 pathway. A study presented in preliminary form on May 6, 2009 to the Society for Cardiovascular Angiography and Interventions (SCAI) however did not suggest that patients taking Protonix® (pantoprazole) are protected from this potential adverse drug interaction. The SCAI statement, recommended that PPIs be avoided in patients who have recently been treated with coronary artery stents and are at high risk of cardiac complications, such as stent thrombosis (clot formation within the stent).
The most recent study presented at the European Society of Cardiology Congress meeting on August 31, 2009, and published simultaneously in the Lancet, showed that the clinical effectiveness of antiplatelet therapy was not adversely affected by PPIs.
On November 17, 2009 the FDA issued a warning and required a label change for clopidogrel in a press conference at the American Heart Association meetings. This action was taken on the basis of unpublished data.
Patients taking both Plavix® (clopidogrel) and a PPI should contact their physician for advice, particularly if they have been treated with a coronary stent during the last 6-12 months. Certain types of stent (drug eluting stents) may carry a relatively higher risk for clot formation, requiring special consideration. In some cases consultation between your primary care provider, cardiologist and gastroenterologist may be needed.
Cost Consumer reports has published a useful cost comparison for your review. The nonprescription over-the-counter products (Prilosec® OTC and generic equivalents) represent the most cost effective option for most patients.
The material provided on this website is for general informational purposes only. If you need specific medical advice, please contact our office for an appointment.