It seems everyone is taking them. Proton pump inhibitors (PPIs) work by reducing the amount of acid in the stomach. Prilosec OTC, Zegerid OTC, and Prevacid 24HR are sold over the counter for the treatment of frequent heartburn. Nexium (esomeprazole), Dexilant (dexlansoprazole), Prilosec (omeprazole), Zegerid (omeprazole/sodium bicarbonate), Prevacid (lansoprazole), Protonix (pantoprazole), Aciphex (rabeprazole dr) and Vimovo (esomeprazole/naproxen) are available by prescription to treat conditions such as gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and esophagitis. Make no mistake, these drugs should be used when the benefits outweigh the potential harms, but you should be aware of both.
So what should you keep in mind when it comes to PPIs?
1. Fractures: One adverse effect that has received increasing attention is osteoporotic fractures. While long-term use of PPIs may cause a small increase in hip, wrist and spine fractures, short-term and low-dose PPI use does not increase risk.
2. Pneumonia risk: New evidence has emerged that proton pump inhibitors carry an increased risk of bacterial pneumonia. The reason for this may be bacterial overgrowth in the lungs due to the change in pH of respiratory secretions or colonization of the upper GI tract with bacteria due to reduced acids in the stomach.
3. How to take PPIs: All of these medicines work best if taken on an empty stomach 30 – 60 minutes before breakfast.
4. Money: Many patients are paying huge dollars for brand name PPIs. They shouldn’t be expensive. Many PPI’s are generic and some are over the counter and no studies have shown that the expensive brand name PPIs are any better. Dexilant, Vimovo and Nexium will cost you more money.
5. Once a day or twice a day? The majority of patients respond to a single daily dose of a PPI for heartburn or reflux symptoms but some will require twice daily dosing. After an active bleeding ulcer you may need a twice daily PPI for a few weeks. Know that if a once daily PPI isn’t relieving your symptoms you can talk to your doc about twice a day.
6. Clostridium difficile (C-diff) diarrhea risk: The use of proton pump inhibitors increases your risk of infectious C-diff diarrhea. Use of PPIs is also associated with increased risk of recurrence of C-diff after treatment.
7. Rebound indigestion: You may have worsening symptoms after you stop taking PPIs. Rebound symptoms should resolve within 5 – 7 days of going off your PPI medication and if they don’t, you can talk to your doctor about restarting.
8. Drug Interactions: The most important interaction is with the blood thinner Plavix (clopidogrel). Some PPIs (Prilosec and Nexium) reduce the blood thinning (antiplatelet) activity of clopidogrel more than others. Pantoprazole (Protonix), lansoprazole (Prevacid) or Dexilant have less effect on the activity of Plavix.
9. How fast do they work? It can take several days before your stomach pain gets better when you start on a PPI.
Dexilant, Vimovo, and Nexium are among the PPIs that don’t have generic equivalents, and can cost around $75 to $250 for a one-month supply. They are also likely to be considered Tier 2 or 3 medications by insurance plans, if they’re covered, meaning a higher copay. In contrast, generics like omeprazole and pantoprazole are covered by most insurance plans as Tier 1 medications, meaning you’ll pay only your lowest copay. They’re also available at most pharmacies for under $15 per month and are included in some generic discount programs for even lower prices.
Poor control of blood pressure (BP) is bad news, and is associated with enhanced risk of cardiovascular disease. Therapy with a single blood pressure medication fails to reach goals 75% of the time. This is just one reason that single pill combinations (two different blood pressure medications in one pill) make perfect sense.
Combining medications that have different and often complementary actions can lead to more complete and prompt reductions in BP. Side effects may also be better as certain classes of high blood pressure medications reduce adverse effects associated with, other medications. Of course one pill is easier than two, so single pill combinations also provide for better patient compliance.
What are the most popular single pill combinations for blood pressure control?
1. Calcium channel blocker + angiotensin converting enzyme inhibitor (ACE inhibitor) combinations like amlodipine/benazepril (Lotrel), work well and are associated with fewer adverse effects and better outcomes than either med alone. Amlodipine also comes paired with an angiotensin receptor blocker (ARB) in two brand name drugs: Exforge (amlodipine/valsartan) and Twynsta (amlodipine/telmisartan). The main side effect of amlodipine, swelling in the legs, is eliminated with the combination pill.
2. ACE Inhibitor + hydrochlorothiazide (HCTZ) combinations offer tons of choices and all are generic which is great. Benazepril/hctz, lisinopril/hctz, enalapril/hctz and other combinations have been shown to be more effective than the two separately with better side effects (they cancel out problems with potassium).
3. Angiotensin receptor blocker (ARB) + HCTZ single pill combinations. Take advantage here of some of the newer generics in this class of excellent blood pressure medications. Avalide (irbesartan/hctz), Diovan HCT (valsartan/hctz) and Hyzaar (losartan/hctz) are all available in generic form. Again, these single pill combos not only make adherence easier but work together better than they do alone.
If you are taking more than one pill for your blood pressure, get to know these combinations. Combination antihypertensive therapy, especially with the single pill formulations just discussed, can more effectively control blood pressure and improve side effects and compliance while lowering costs.
It’s a no brainer.
Many generic combination blood pressure medications, such as lisinopril/hctz, benazepril/hctz, and atenolol/chlorthalidone are available for cash prices as low as $4 – $5 per month through some pharmacies’ discount generic programs. Others such as amlodipine/benazepril and metoprolol/hctz can cost a bit more, around $15 – $30 per month without insurance. All of the above blood pressure generics should be covered under most insurance plans as Tier 1 drugs, meaning you’ll pay only your lowest copay.
If you take prescription drugs to treat a chronic illness, it’s possible to save more than 50% off cost of your medication by simply splitting your pills.
Sadly, it’s not all that easy to know when pill splitting is all right.
Not all pills can be split. However, many doctors and insurance companies are advising this strategy with an increasing number of medicines. (It’s also worth noting that the American Medical Association, the American Pharmacists Association, and most pharmaceutical companies oppose pill-splitting.)
Drugs that can be usually be split include Lipitor (atorvastatin), Zocor (simvastatin), Crestor (rosuvastatin), Norvasc (amlodipine), Zestril (lisinopril), Accupril (quinapril), Glucophage (metformin), Synthroid (levothyroxine), Zyprexa (olanzapine), Celexa (citalopram), Paxil (paroxetine), Zoloft (sertraline), Klonopin (clonazepam), Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), and a number of others.
Drugs that should usually not be split include capsules, chemotherapy drugs, birth control pills, seizure-related medications, and any pill that has a coating or other controlled- or extended-release feature.
Be sure to check with your doctor prior to splitting any medication.
Some other things to watch for:
• Is it scored? Tablets that are scored can be easily split and have been evaluated by the FDA for safety.
• Invest in a pill splitter. Pill splitters are very inexpensive and carried by most pharmacies. If you’re going to split a pill, spend the $5.
• Only split once. It is only recommended that you split pills in half, not any smaller. The dose per piece is too likely to be uneven and pills may shatter or crumble.
• Unequal halves. Even scored tablets can be difficult to split into two perfect halves, and medicine is sometimes distributed unevenly within a single tablet. Buy a pill splitter to help and don’t split with a knife.
• Crumbs. Tablets that are round or too small may crumble easily or unevenly when split and that will affect the dose you are actually getting.
• Don’t forget! Patients who are given a higher dose pill and told to take half may forget to do so, resulting in a double dose of medication. Splitting is not recommended for patients with poor eyesight, arthritis, memory problems or impaired thinking.
• Don’t split in advance. Some pills may deteriorate after being split, and taking two halves of the same pill consecutively will get you the most even dosing.
• To split or not to split? When in doubt about whether your pill can be split, check the package insert or ask your doctor or pharmacist.
Keep calm and save on . . .