Picking a PPI: It comes down to cost
The Journal of Family Practice. 2008 April;57(4):231-235
April 1, 2008|The Journal of Family Practice
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No need to be bound to the PPI you’ve always prescribed—efficacy is similar, and all have good adverse-event profiles
It is promising that data which demonstrate safe and effective use of these agents for longer than 10 years are available.2,28
TABLE 1
Similarities and differences among proton pump inhibitors2,8-12,25,34,35
| PANTOPRAZOLE PROTONIX | LANSOPRAZOLE PREVACID | ESOMEPRAZOLE NEXIUM | OMEPRAZOLE PRILOSEC, ZEGERID | RABEPRAZOLE ACIPHEX | NOTABLE SIMILARITIES AND DIFFERENCES | |
|---|---|---|---|---|---|---|
| Available strengths | 20 mg, 40 mg tabs 40 mg/vial 40 mg granules for suspension | 15 mg, 30 mg caps Packets for suspension, SoluTabs | 20 mg, 40 mg caps, per vial, packet for suspension | 10 mg, 20 mg, 40 mg caps 20 mg, 40 mg Zegerid packet 20 mg tab (OTC) | 20 mg tabs | Injectable options: Pantoprazole, esomeprazole Generic Prilosec and Protonix are available |
| Renal dose adjustment | No dosage adjustment needed | |||||
| Hepatic dose adjustment | > 40 mg/d not studied in hepatic impairment | Consider lower dose in severe hepatic impairment | Max 20 mg/d in severe hepatic impairment | Consider lower dose in hepatic impairment | Consider lower dose in severe hepatic impairment | No differences Consider decreased dose in hepatic impairment |
| Pregnancy category | B | B | B | C | B | All are pregnancy category B except omeprazole, which is C |
| Pediatric use | Safety and efficacy not established for patients < 18 yo | FDA approved for pediatric use except patients ≤ 2 yo | Safety and efficacy not established for patients ≤ 12 yo | FDA approved for pediatric use except patients ≤ 2 yo | Safety and efficacy not established for patients < 18 yo | Lansoprazole and omeprazole are FDA approved for pediatrics No PPI is approved for use in patients ≤ 2 yo |
| Major drug interactions** | ||||||
| Formulation stability | Do not break, crush, or chew tablets | Capsules can be opened and granules sprinkled onto soft food/beverage* or swallowed intact SoluTab and oral suspension packets can be dissolved with water | Capsules can be opened and granules sprinkled onto apple-sauce or swallowed intact Oral suspension packets can be dissolved with water | Capsules can be opened and granules sprinkled onto apple-sauce or swallowed intact Zegerid capsules should not be opened | Do not break, crush, or chew tablets | Suitable for NG administration: esomeprazole, omeprazole (Zegerid), lansoprazole Lansoprazole, omeprazole, and pantoprazole can be compounded into oral suspensions at retail pharmacies if the patient has difficulty swallowing tablets/capsules |
| Cost *** | $128 brand $100 generic | $122-$161 | $150-$165 | $115-$216 brand $64 (20 mg generic) $22 (#28 OTC) $15 (#28 OTC generic) No generic for 40 mg | $160 | Prilosec is the only PPI available OTC Prices at retail pharmacies may differ |
| Applicable soft foods and beverages are applesauce, cottage cheese, Ensure pudding, yogurt, strained pears, apple juice, tomato juice, or orange juice. | ||||||
| ** In addition to cytochrome P450 enzyme interactions, H2receptor antagonists and proton pump inhibitors can affect drugs that rely on acid for absorption (i.e., can decrease the absorption of bases like ketoconazole, iron, or cefpodoxime and increase the absorption of acids like diazepam). There have been case reports of elevated INRs with warfarin and the use of proton pump inhibitors. Omeprazole can raise levels of diazepam, warfarin, and phenytoin. | ||||||
| ***Cost information accessed at https://www.drugstore.com or https://www.cvs.com on March 10, 2008 and is for #30 unless otherwise specified. | ||||||
TABLE 2
Cost comparison of proton pump inhibitor regimens* for 8 conditions8-12,25,29
| PANTOPRAZOLE PROTONIX | LANSOPRAZOLE PREVACID | ESOMEPRAZOLE NEXIUM | OMEPRAZOLE PRILOSEC, ZEGERID | RABEPRAZOLE ACIPHEX | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| DOSAGE | PRICE | DOSAGE | PRICE | DOSAGE | PRICE | DOSAGE | PRICE | DOSAGE | PRICE | |
| GERD | 20 mg QD 4-8 wk | $128-$256 $110-$220 (G) | 15 mg QD up to 8 wk | $322 | 20 mg QD 4-8 wk | $165-$330 | 20 mg QD 4 wk | $142 $15 (OTC, G) | 20 mg QD 4-8 wk | $160-$320 |
| Erosive esophagitis associated with GERD | 40 mg QD 8-16 wk **40 mg QD IV 7-10 d | $256-$512 $220-$440 (G) | 30 mg QD 8-16 wk | $308-$616 | 20-40 mg QD 4-16 wk **20-40 mg QD IV up to 10 d | $150-$660 | 20 mg QD 4-8 wk | $142-$284 $15-$30 (OTC, G) | 20 mg QD 4-16 wk | $160-$640 |
| Maintenance of healing of erosive esophagitis | 40 mg QD up to 12 mo | $1536 or $1320 (G) /12 mo | 15 mg QD up to 12 mo | $1932/12 mo | 20 mg QD up to 6 mo | $990/6 mo | 20 mg QD up to 12 mo | $1704 or $180 (OTC, G)/12 mo | 20 mg QD up to 12 mo | $1920/12 mo |
| Hypersecretory conditions*** | 40 mg BID 80 mg BID IV 7-10 d | $256 $220 (G) | 60 mg QD | $309 | 40 mg BID | $300 | 60 mg QD | $426 or $45 (OTC, G) | 60 mg QD | $480 |
| Active duodenal ulcer | 40 mg QD 2-4 wk | $64-$128 $55-$110 (G) | 15 mg QD 4 wk | $161 | — | — | 20 mg QD 4-8 wk | $142-$284 $15-$30 (OTC, G) | 20 mg QD 4 wk | $160 |
| Active gastric ulcer | 40 mg QD up to 8 wk | $256 or $220 (G) | 30 mg QD up to 8 wk | $309 | — | — | 40 mg QD 4-8 wk | $216-$432$30-$60 (OTC, G) | 20 mg QD 3-6 wk | $112-$224 |
| Reduce risk of NSAID-associated gastric ulcer | 40 mg QD | $128 or $110(G)/mo | 15 mg QD up to 12 wk | $161/mo | 20-40 mg QD up to 6 mo | $150-$165/mo | 20 mg QD | $142 or $15 (OTC, G)/mo | — | — |
| Helicobacter pylori (Always part of a 3-drug combination) | 40 mg BID 10-14 d | $85-$120 $73-$103 (G) | 30 mg BID 10-14 d | $103-$144 | 40 mg QD 10-14 d | $50-$75 | 20 mg BID 10 d | $95 $15 (OTC, G) | 20 mg BID 7 d | $80 |
| * Doses in italics are from Ref. 29. | ||||||||||
| ** For GERD in patients with a history of erosive esophagitis. | ||||||||||
| *** Starting doses listed. Several years of therapy may be necessary. | ||||||||||
