Part 3: Proto pump Inhibitors (PPIs) in detail
By Nur Choudhury
Proton pump inhibitors (PPIs) have been available for over two decades, and since the introduction of lower cost generic PPIs, the use of these agents has continued to grow.
Peptic Ulcer Disease
When prescribed for peptic ulcer disease, PPIs offer acid suppression, ulcer healing and symptomatic relief superior to that provided by any other anti-secretory therapy. Four to eight weeks of full dose PPI treatment is usually recommended to people with peptic ulcer who have tested negative for Helicobacter pylori (H. pylori) and are not taking nonsteroidal anti-inflammatory drugs (NSAIDs).
NSAID induced ulcers NSAIDs increase the risk of dyspepsia and ulceration. Up to 25% of long-term users of NSAIDs develop peptic ulcers.
PPIs have been shown to be superior to alternative treatments in both the healing of NSAID induced ulcers, and in preventing recurrences of these ulcers.
Eight weeks of PPI therapy is usually prescribed to those with a peptic ulcer related to NSAID use. Helicobacter pylori eradication H. pylori has been associated with both gastric and duodenal ulcers. Successful eradication of H. pylori with a PPI in combination with appropriate antimicrobial agents has been shown to facilitate ulcer healing and decrease the incidence of ulcer recurrence in H. pylori positive patients. PPIs are normally prescribed in combination with antibiotics for one week, however, complicated cases PPIs may need to be continued for a further three weeks after H. pylori eradication.
Gastro-Oesophageal Reflux Disease
PPIs are effective both for controlling symptoms of gastroesophageal reflux disease (GORD) and healing oesophagitis. Initial treatment with a PPI should be given for 4-8 weeks but long-term treatment may be required in patients with severe oesophagitis.
Choice of PPI
Although studies exist comparing different PPIs, and some may suggest superiority of one agent over another, current NICE guidance does not recommend any particular PPI.
The NICE Guideline Development Group considered that a class effect could be assumed for all PPIs and the choice of agent should be based on patient preferences and clinical circumstances.
Five PPIs are licensed for use in the UK (esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole).
It should be noted that the licensed indications and the potential for interactions may differ between individual drugs, this may influence the hoice of PPI.
PPIs are usually well tolerated. The most common side effects include headaches, nausea, abdominal pain, constipation, flatulence, diarrhoea, rash and dizziness. Recent reports have suggested that PPIs may be associated with rare additional, potentially more serious, adverse effects.