9 Things You Might Not Know About Proton Pump Inhibitors (PPIs)

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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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.

Dr. O

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.

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