Picking a PPI: It comes down to cost
No need to be bound to the PPI you’ve always prescribed—efficacy is similar, and all have good adverse-event profiles
Step-up and step-down therapy
Step therapy was a much larger issue prior to the availability of generic omeprazole and pantoprazole. The relative novelty of these agents combined with higher cost of therapy and unknown long-term safety information as well as the availability of effective alternatives justified the argument for step-up therapy.
Health care systems and insurance providers encouraged short-term use of PPIs, either prior to H2 receptor antagonists (step-down therapy) or only after failure of H2 receptor antagonists (step-up therapy). Those who favored step-up therapy took into account the cost advantage of H2 receptor antagonists. Those who favored step-down therapy believed patients on H2 receptor antagonists may experience worsening control of the disease and would therefore need to utilize more health care resources, offsetting the lower costs of H2 receptor antagonists. Further, for indications like the treatment of H. pylori, compliance to therapy and corresponding efficacy may be compromised by the use of an H2 receptor antagonist in place of a PPI. Of the 2 approaches, cost effectiveness studies favor the step-down approach.30-33
Switch to an H2 blocker? Proponents of step-down therapy reasoned that many patients are placed on PPIs and continued indefinitely without re-evaluation. The only way to see if a PPI is still needed is to decrease the dose, switch to an H2 receptor antagonist, or completely discontinue acid-suppression therapy after symptom resolution.
At this time, omeprazole is the only PPI available OTC; it typically retails at $22 for 28 capsules. A generic version of the OTC omeprazole product has been approved. The cost is generally $13 to $15 for 28 capsules. Each H2 receptor antagonist is available as a generic, and OTC at half prescription strength. Of note, famotidine 20-mg tablets and ranitidine 150-mg and 300-mg tablets are available on many of the $4 prescription plans at retail pharmacies.
Your patient reports he has been taking omeprazole 20 mg daily, as you prescribed, for the past 2 weeks. His heart-burn symptoms have improved and he no longer needs to use Tums for breakthrough symptoms, as he did when he was taking Pepcid.
You considered pantoprazole and omeprazole because they are both available in generic form. Since there are no significant differences in efficacy of the 2 drugs for the treatment of GERD, you decided to prescribe pantoprazole because it will cost less for the patient, who has no prescription insurance. The pharmacy calls you, asking if generic omeprazole could be used instead due to the cost difference.
According to https://www.drugstore.com, generic pantoprazole would cost the patient $110 per month and generic omeprazole would cost the patient $63 per month.
Even though costs at local pharmacies vary and are often higher than online costs, the savings to the patient seemed significant enough to change
Equal efficacy
The first PPI, Prilosec, was approved in 1989, and 4 additional agents have become available. All are equally efficacious at equipotent doses.
Long-term safety
Although there has been concern about potential for several different adverse events with long-term PPI use, it is important to remember that the majority of these data are either conflicting or derived from case-control studies. The latter cannot prove cause and effect, but can describe potential associations that merit further investigation.
Step therapy
Whether to lower the PPI dose or switch to an H2 receptor antagonist should be considered in all patients and attempted in most patients who have been on PPIs long enough for adequate ulcer healing or who have been symptom-free.
Consider the cost to the patient
Given the similarities in interaction potential, adverse events, and efficacy, select the PPI on the basis of cost to the patient.
