PPIs

Different Proton Pump Inhibitors

   (Other PPIs: Ilaprazole, Picoprazole, Tenatoprazole, Timoprazole)

Do not assume because a dose is shown it is the safe dose. It may vary according to age and body build.

The most common brand names are shown though they may also be known under other names in other parts of the world.

Research evidence has shown all PPIs are as effective as each other (though the drugs companies may try to make us believe otherwise) but some may be better tolerated by some patients. [a-iv][a-v]

* Astra Zeneca (who make the drug) claims 40mg esomeprazole is equivalent to 20mg omeprazole and one (Astra Zeneca sponsored) trial showed 40mg esomeprazole was better at reducing acid production than 20mg omeprazole. [a-vi]

Another study published February 2015 [a-vii]  also compared 40mg esomeprazole with 30mg lansoprazole and 40mg Pantoprazole finding: "esomeprazole was more effective".

Research funded by Reckitt Benkiser (who make the drug) found Gaviscon was no less effective than standard dose omeprazole for a 24hr period. [a-viii]

A study published in Cureus October 2024, comparing the  Efficacy of Dexlansoprazole, Pantoprazole, Esomeprazole, and Rabeprazole in Achieving Optimal 24-Hour Intragastric pH Control, concluded "Dexlansoprazole's dual-delayed release mechanism demonstrates superior acid suppression compared to traditional PPIs and placebo." However, it had compared the double dose (60mg) of dexlansoprazole with standard doses of the other PPIs.

The molecular diagrams above compare omeprazole (left) and pantoprazole (right). The active part is the same.

They should not be self medicated for more than a couple of weeks without a doctor's approval since they may mask the symptoms of oesophageal cancer.

Although there have been many scare stories circulated regarding their safety, these have been triggered by studies showing possible associations rather than causation and have since been rebuffed.

The chapter "PPI Dangers" looks at the scientific evidence.

Possible side effects 

Side effects are rare but th emost common include headaches, diarrhoea and constipation.

If affected, switching to an alternative brand usually works.

Benefits of PPIs

PPIs have also been found to have a chemo-protective effect, reducing the risk of oesophageal cancer and possibly colorectal and female cancers (breast, ovarian, cervical and endometrial. See Can PPIs protect against Cancer? and Other Cancers.

Those who have developed Barrett's Oesophagus are recommended to remain on PPIs for life (with regular surveillance every few years to look for early signs of any pre-cancerous mutation.

My PPIs are not working

There may be many reasons why people don't peceive the drugs are working or may feel they have stopped working.

These are discussed on this separate page: PPIs not working.

Coming off PPIs

Based on the self completion of questionnaires, patients coming off PPIs experience a Rebound effect, experiencing worse acid reflux symptoms for a few days.

However, the existence of the rebound effect, rebound acid hypersecretion (RAHS) is controversial.

A 2018 paper in Therapie suggested, "Daily PPI exposure for more than 4 weeks is likely to trigger a rebound of acid hypersecretion about 15 days after discontinuation, and lasting from a few days to several weeks depending on the duration of the exposure."

Unwarranted overuse

This 2024 discussion paper,  Are OTC Proton Pump Inhibitors a Boon Or a Curse?, looked at unwarranted overuse of PPIs stating, "Most the patients purchasing OTC PPIs are unaware that they do not offer immediate relief from the acidity (or heartburn) problem, and it could be a minimum of 1 to 4 days before exhibiting any observable therapeutic benefits. "
It concluded, "In a nutshell, OTC PPIs could definitely prove to be a boon for patients if there is a multi-faceted and intentional approach by a team of pharmacists, prescribers, and managers for OTC PPIs necessitating a clinically justifiable use, and minimizing potential therapy duplication of OTC PPI use along with prescription PPIs."

Deprescribing

Because of the belief of harmful effects of PPIs, some interventions are employed to reduce PPI usage. In an April 2024 paper published in the British Medical Journal, the Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse was assessed finding them "without evidence of clinically significant harms or benefits. Thus, the primary benefits are likely to be reduced pill burden for patients and reduced drug costs for health systems."

The 2022 AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors provided Best Practice Advice for de-prescribing of PPIs when their use was not warrented. However they did provide this guidance for when PPIs ere deemed necessary:

Best Practice Advice 5

Patients with known Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should generally not be considered for a trial of de-prescribing.

Best Practice Advice 6

PPI users should be assessed for upper gastrointestinal bleeding risk using an evidence-based strategy before de-prescribing.

Best Practice Advice 7

Patients at high risk for upper gastrointestinal bleeding should not be considered for PPI de-prescribing.

Best Practice Advice 10

The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PAAEs [PPI associated adverse event]. The presence of a PAAE or a history of a PAAE in a current PPI user is not an independent indication for PPI withdrawal. Similarly, the presence of underlying risk factors for the development of an adverse event associated with PPI use should also not be an independent indication for PPI withdrawal.

Also see, from the chapter on PPI safety:

Concerns over PPI use

Looking at the evidence regarding stories presented in popular media of concerns.

Chemo-protection of PPIs

Research links showing PPIs reduce cancerous mutations of Barrett's' cells and their modus operandi.

Page updated 10 December 2024