Proton Pump Inhibitors Flashcards
pantoprazole brand name
Protonix
omeprazole brand names
Prilosec or Losec
If a patient needs a PPI but cannot swallow pills, what are your options?
In patients unable to swallow pills or capsules, options include an oral suspension of lansoprazole and a powder formulation of omeprazole-sodium bicarbonate for oral suspension.
lansoprazole brand name
Prevacid or Prevacid Solu Tab
Administration instructions/patient education for how to take PPI
Take 30-60 minutes before breakfast. If taking twice a day, take 30-60 minutes before breakfast and 30-60 minutes before dinner. Do not take with an anti-antisecretory agents including histamine-2 receptor antagonists (H2RAs), analogues of prostaglandin E (eg, misoprostol), and somatostatin analogues (eg, octreotide), because of the marked reduction in acid inhibitory effects.
Plan for tapering/discontinuing PPI
We gradually taper PPI therapy in patients treated with PPIs for longer than six months. For patients on a standard or high-dose PPI (eg, omeprazole 40 mg daily or twice daily), we decrease the dose by 50 percent every week. For patients on twice daily dosing, the initial reduction can be accomplished by decreasing the dosing to once in the morning before breakfast until the patient is on the lowest dose of the medication. Once on the lowest dose for one week, the patient is instructed to discontinue the PPI. However, no specific method for discontinuing PPI therapy has been proven effective, and no approach is universally accepted. [21,22].
Studies have demonstrated rebound gastric acid hypersecretion following discontinuation of PPIs in patients with long-term use. The reasons are not entirely clear, but appear to be due in part to the suppression of antral somatostatin expression, resulting in an increase in antral gastrin release and subsequent disruption of normal pH-related feedback inhibition of acid secretion that occurs after a meal [1]. (See “Physiology of gastric acid secretion”, section on ‘Tolerance’.)
dexlansoprazole brand name
Dexilant
esomeprazole brand name
Nexium
rabeprazole brand name
Aciphex; AcipHex Sprinkle [DSC]
PPI / drug interactions table by PPI
What labs to monitor for people on long term PPI’s
Magnesium – We obtain serum magnesium levels prior to starting a PPI in patients who are expected to be on long-term (≥1 year) treatment or in patients who take PPIs in conjunction with other medications associated with hypomagnesemia (eg, diuretics). In addition, we obtain magnesium levels periodically in such patients while they are taking a PPI. The frequency of testing is based on the clinical history and the presence of symptoms of hypomagnesemia. As an example, in patients with a history of arrhythmias or QT interval prolongation, we monitor magnesium levels every six months. The management of hypomagnesemia is discussed in detail separately. (See “Hypomagnesemia: Evaluation and treatment”.)
●Vitamin B12 – We also obtain vitamin B12 levels yearly in patients on long-term PPIs [15]. However, routinely monitoring vitamin B12 levels is controversial. (See ‘Magnesium malabsorption’ below and ‘Vitamin B12 malabsorption’ below.)
What PPI’s are available IV
Esomeprazole and pantoprazole
If your patient is on X drugs, you need to check UTD for whether to give them:
Clopidogrel - Some data suggest decreased activation of clopidogrel when used in conjunction with omeprazole due to shared hepatic cytochrome P450-mediated metabolism. In 2009, the United States Food and Drug Administration concluded that patients taking clopidogrel should consult with their clinician if they are taking or considering taking a PPI, including over-the-counter PPI preparations [13,14]. However, the relevance of these data remains highly controversial. The interaction of clopidogrel and PPIs are discussed in detail separately. (See “Clopidogrel resistance and clopidogrel treatment failure”.)
●HIV protease inhibitors - PPIs may decrease the absorption of certain HIV protease inhibitors. PPIs are contraindicated in patients being treated with rilpivirine. Atazanavir should not be used in patients who require a PPI dose equivalent to >20 mg omeprazole daily. (See “Overview of antiretroviral agents used to treat HIV”, section on ‘Protease inhibitors (PIs)’.)
●Methotrexate - Coadministration of PPIs with high dose methotrexate appears to be correlated with delayed methotrexate elimination and potentially may lead to methotrexate toxicity if not monitored appropriately.
PPI and kidneys- what to know
Kidney disease – PPIs can cause acute interstitial nephritis. PPI use has also been associated with an increased risk of incident chronic kidney disease (CKD), CKD progression, and end-stage renal disease. However, further studies are needed to help better define an etiologic relationship between PPI use and the development and worsening of CKD. (See ‘Kidney disease’ above.)
Indications for PPI use
Peptic Ulcer Disease, GERD, Zollinger-Ellison syndrome, NSAID associated ulcers, eradication of H-Pylori
see below from UTD
Peptic ulcer disease – PPIs are first-line antisecretory therapy in the treatment of peptic ulcer disease. (See “Peptic ulcer disease: Treatment and secondary prevention”, section on ‘Initial antisecretory therapy’.)
●Gastroesophageal reflux disease – PPIs are indicated in patients with gastroesophageal reflux disease, including for the treatment of erosive esophagitis and as maintenance therapy in patients with severe erosive esophagitis or Barrett’s esophagus. (See “Medical management of gastroesophageal reflux disease in adults”, section on ‘Severe or frequent symptoms or erosive esophagitis’.)
●Zollinger-Ellison syndrome – PPIs, often in high doses, are required to control gastric acid hypersecretion in patients with gastrin-secreting tumors. (See “Management and prognosis of the Zollinger-Ellison syndrome (gastrinoma)”, section on ‘Proton pump inhibitors’.)
●NSAID-associated ulcers – PPIs are indicated in the primary prevention of gastroduodenal ulcers associated with NSAID use. (See “NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity”.)
●Eradication of Helicobacter pylori – PPIs are a component of several first-line and salvage therapy regimens for H. pylori infection. (See “Treatment regimens for Helicobacter pylori in adults”.)
