Practical considerations in the management of proton-pump inhibitors

Abstract

Proton-pump inhibitors (PPIs) are one of the most active ingredients prescribed in Spain. In recent decades there has been an overuse of these drugs in both outpatient clinics and hospitals that has lead to a significant increase in healthcare spending and to an increase in the risk of possible side effects. It is important for health professionals to know the accepted indications and the correct doses for the use of these drugs. On the market there are different types of PPI: omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole. Omeprazole is the oldest and most used PPI, being also the cheapest. Although there are no important differences between PPIs in curing diseases, esomeprazole, a newgeneration PPI, has proved to be more effective in eradicating H. pylori and in healing severe esophagitis compared to other PPIs. In recent years the use of generic drugs has spread; these drugs have the same bioavailability than the original drugs. In the case of PPIs, the few comparative studies available in the literature between original and generic drugs have shown no significant differences in clinical efficacy.Key words: Proton-pump inhibitor. PPI. Omeprazole. Pantoprazole. Lansoprazole. Rabeprazole. Esomeprazole. INTRODUCTIONProton-pump inhibitors (PPIs) represent a family of drugs widely used in our country. The advent in the nineties of PPIs was a great revolution in the treatment of ulcer disease and gastroesophageal reflux. The main problems of PPIs at present time are its overuse and the errors in the therapeutic indication. This fact leads to a considerable health economic cost and the risk of long-term side effects. In this review the main problems of PPIs prescription, their indications, the differences between PPIs and tips on their use are discussed. Brief historical memory: since alkaline diets until PPIsThe treatment of ulcer disease and gastroesophageal reflux disease (GERD) in the early twentieth century was the prescription of alkaline foods like milk, eggs and puree (1). Later, there were products as sodium bicarbonate that improved symptoms but did not prevent complications. Surgical treatment consisted of different types of gastric surgeries for peptic ulcer disease and Nissen fundoplication for GERD (2).In the mid twentieth century the use of muscarinic antagonists was introduced, atropine being its main active ingredient. Acids secretion was partially inhibited by blocking the muscarinic receptor of the parietal cell. However, these drugs had little effectiveness and numerous adverse effects due to the amount of muscarinic receptors distributed throughout the body. E-type prostaglandin was discovered later, but, again, the limitations of these substances were their short half life and side effects. An important progress in gastric antisecretory therapy was the appearance of H 2 receptors antagonists (H 2 blockers) (3). The most used were ranitidine and famotidine. These drugs established a substantial change by blocking the action of histamine receptor in gastric parietal ...

Limited effectiveness with a 10‐day bismuth‐containing quadruple therapy (Pylera®) in third‐line recue treatment for Helicobacter pylori infection. A real‐life multicenter study

“…3,7,8,21 This decision, although controversial and not supported by head-to-head comparisons, could be explained by some data pointing to better overall eradication rates for triple therapies including new-generation PPIs. 22,23 An important finding of this study is that overall eradication rates remained suboptimal despite high-dose esomeprazole. Optimal duration of therapy is another key question that remains unanswered.…”

Economic evaluation of endoscopic radiofrequency ablation for the treatment of dysplastic Barrett’s esophagus in Spain

“…Due to the current lack of Spanish guidelines for the diagnosis and treatment of patients with BE, it was estimated that the management of BE in Spain would not differ significantly from the European recommendations (3,11,12,25). Consequently, in order to ensure that the SoC (35,36) were not considered in this analysis as they implied a cost that was equal for all interventions compared in this study. Moreover, the analysis was based on a mathematical model and therefore has limitations due to the variability in the data sources included in the model and the assumptions applied in their absence.…”

Appropriateness of the use of proton pump inhibitors in the Emergency Department of a Spanish university hospital

“…PPIs are the second most consumed group of drugs, accounting for 626 million Euros a year and a total of 4.8% of the prescription drug budget in Spain (1). PPI use has markedly increased over the last years, by more than 500% between 2000 and 2012 (2), and Spain has a particularly high rate of use compared to other European Union countries (3)(4)(5)(6).…”

“…According to the drug label of the Spanish Agency of Medicinal Products and Medical Devices' (7), PPI are approved for the following conditions: benign gastrointestinal ulcers, symptomatic gastroesophageal reflux disease (GERD), treatment of gastrointestinal ulcers due to non-steroidal anti-inflammatory drugs (NSAID) and prevention in at risk patients, and treatment and prevention of gastrointestinal ulcers due to Helicobacter pylori and Zollinger-Ellison syndrome. The following risk factors should be considered with regard to NSAID-induced ulcer prevention (3,5,6,(8)(9)(10): age over 60 years, past history of ulcers or other complications, long courses of NSAID treatment at high doses, current concomitant therapy with other gastro-erosive drugs (other NSAID, anticoagulants, corticoids, selective serotonin reuptake inhibitors antidepressants) and severe comorbidities. In addition, PPIs are frequently used off label for conditions such as functional dyspepsia, uninvestigated dyspepsia and stress ulcer prevention in selected patients (critical condition, assisted ventilation, sepsis, severe burns and polytrauma) (3,5,6,(8)(9)(10).…”

“…The following risk factors should be considered with regard to NSAID-induced ulcer prevention (3,5,6,(8)(9)(10): age over 60 years, past history of ulcers or other complications, long courses of NSAID treatment at high doses, current concomitant therapy with other gastro-erosive drugs (other NSAID, anticoagulants, corticoids, selective serotonin reuptake inhibitors antidepressants) and severe comorbidities. In addition, PPIs are frequently used off label for conditions such as functional dyspepsia, uninvestigated dyspepsia and stress ulcer prevention in selected patients (critical condition, assisted ventilation, sepsis, severe burns and polytrauma) (3,5,6,(8)(9)(10).…”