Drug Update: Peptic Ulcer Disease - RX | OB/GYN News | Find Articles at ...
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PROTON PUMP INHIBITORS (PPIs)
These drugs decrease acid secretion. They have eclipsed all other
nonantibiotic agents for treating peptic ulcer disease. The plasma
half-life of PPIs is 1-2 hours. They should be taken 30 minutes before
breakfast. If a second dose is needed, it is taken 10-12 hours after the
morning dose and 30 minutes before a meal or snack. All drugs in this
class have a low risk of side effects. The use of PPIs in pregnancy has
not been approved by the Food and Drug Administration, but studies are
now underway to establish safety. PPIs are excreted in breast milk, so
nursing mothers should stop breast-feeding. Although PPIs increase the
gastrin concentrations, no causal relationship with gastric tumors
established. Continuous use of omeprazole or lansoprazole for up to 5
years led to no cancers in humans and did not increase the risk for
polyp formation or colon adenocarcinoma. Hyperplasia of
enterochromaffin-like cells occurs but is self limiting, nondysplastic,
and nonneoplastic. Dosage adjustments are generally not needed in the
elderly, but some adjustment of lansoprazole and rabeprazole dosages may
be needed in patients with impaired kidney function (+)
Drug Dosage Cost/Day (*) Comment (*)
omeprazole 20-40 mg/day $8.28 Oldest and most widely
(Prilosec) (20 mg b.i.d.) prescribed PPI. A
first-choice agent for a
standard triple-drug
regimen. First approved
at 20 mg/day, but many
now use 20 mg b.i.d.
Least favorable drug
interaction profile
compared with other PPIs.
Affects warfarin,
benzodiazepines, etc.
Reaches maximum effect in
5-7 days. Comes in
delayed-release capsule
form, like lansoprazole
and esomeprazole.
lansoprazole 15-30 mg/day $4.00 Approved by the FDA at a
(Prevacid) (30 mg/day) dosage of 15 mg/day, but
most clinicians prescribe
30 mg/day. Generally well
tolerated. Can raise
theophylline levels
modestly, so closely
monitor patients with
asthma and chronic
obstructive pulmonary
disease. Reaches maximum
effect in about 5 days.
One of the first-choice
agents for a standard
triple-drug regimen.
pantoprazole 40 mg/day $3.13 Appears to have best
(Protonix) safety record in terms
of drug-drug
interactions. Better
absorbed than the other
PPIs, with higher
bioavailability. Higher
circulating blood levels
means consistent
long-term results.
Reaches maximum effect in
5-7 days. Intravenous
formulation approved by
the FDA.
rabeprazole 20 mg/day $3.80 Fastest onset of action
(Aciphex) among PPIs. In the first
24 hours, causes the
greatest consistent
median elevation in
gastric pH-important for
patients who use a PPI
only as needed. Like
other PPIs, decreases
the amount of
ketoconazole absorbed
into the body secondary
to its effect on gastric
pH. Reaches maximum
effect in about 5 days.
esomeprazole 20-40 mg/day $4.00 (**) Newest PPI on the market.
(Nexium) S-enanatiomer of omepra-
zole, with signifi-
cantly reduced risk of
drug interactions.
Reaches maximum effect
in 5-7 days. Clinical
trials underway to study
efficacy of on-demand
therapy; also being
investigated as an
intravenous formulation.
ANTIBIOTICS
Drug Dosage Cost/Day (*) Comment (*)
clarithromycin 500 mg b.i.d. $8.02 This dosage is also
(Biaxin available in Prevpac, a
triple-drug regimen that
is highly effective for
eradicating H. pylori.
The Prevpac convenience
pack also contains
lansoprazole 30 mg b.i.d.
and amoxicillin 1,000 mg
b.i.d. The cost per day
for Prevpac is $18.57.
In contrast, the total
average wholesale price
of this triple-drug
regimen taken as single
agents is $16.84. Another
popular combination is
clarithromycin 500 mg
b.i.d. with amoxicillin
1,000 mg/day and
omeprazole 20 mg b.i.d.
Use only when necessary
in women who are
pregnant. No dosage
adjustment usually needed
in the elderly on in
women who are nursing.
Dosage adjustment needed
for patients with severe
kidney impairment.
amoxicillin 1,000 mg/day $0.82 Also available at a
dosage of 1,000 mg b.i.d.
in Prevpac, which also
contains lansoprazole 30
mg b.i.d. and
clarithromycin 500 mg
b.i.d. The cost per day
for Prevpac is $18.57.
In contrast, the total
average wholesale price
of this triple-drug
regimen taken as single
agents is $16.84. Another
popular combination is
amoxicillin 1,000 mg/day
with omeprazole 20 mg
b.i.d. and clarithromycin
500 mg b.i.d. Use with
caution in women who are
pregnant or nursing. No
age-related dosage
adjustment usually
needed.
metronidazole 500 mg b.i.d. $1.60 Use when patient is
allergic to amoxicillin
or is infected with
amoxicillin-resistant
strain. Use with a PPI
and clarithromycin
500 mg b.i.d. Can be used
during pregnancy when
potential benefit exceeds
potential risk. Use with
caution in nursing
mothers as the drug will
enter breast milk. Dosage
adjustment in the elderly
may be needed based on
serum levels. Use with
caution in patients who
drink alcohol.
(*)Cost/day is based on the average wholesale price for a 100-unit
container, or closest available size, of the generic formulation (unless
otherwise indicated), as listed in the 2001 Red Book.
(**)Cost/day is based on the average wholesale price, as supplied by the
manufacturer for a 30-unit container.
(+)Comments reflect the opinions and expertise of the following sources:
Dr. Richard H. Hunt, professor of medicine, division of
gastroenterology, McMaster University Medical Center, Hamilton, Ont.
Dr. Joseph Pisegna, chief of gastroenterology and hepatology, Veterans
Affairs Greater Los Angeles Healthcare System.
Dr. Peter P. Toth, clinical associate professor, Southern Illinois
University, Carbondale. He also practices family medicine at
Sterling-Rock Falls Clinic, Sterling, III.
