Pharmacy/PPI meds

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Question
My 61 year old husband has a long history of gastroesophageal reflux disease (GERD) with Barretts esophagus. He has been on Prilosec (omeprazole) for 20 years and it has done an excellent job of controlling his GERD and healing his esophagus. Recently he has been diagnosed with laryngopharyngeal reflux and the doctor changed his Prilosec to Protonix (pantoprazole)saying that pantoprazole is longer acting. In your opinion, is there any actual difference between the protein pump inhibitor drugs? Also, can pantoprazole be taken long term? (for years?) I was concerned to read that pantoprazole can cause malignant tumors in animal studies.Pantoprazole seems to have a longer list of side effects than omeprazole.Thank you for your time and consideration. You are much appreciated.

Answer
Dear Maria,

Thank you for your question.  In terms of efficacy (ie, ability to reduce gastric acid), there is no difference between the proton pump inhibitors (PPIs).  Pantoprazole and Omperazole may differ in their pharmacokinetic properties.  Yes, pantoprazole may have a longer duration of action, and as such, is usually taken once a day, whereas ompreprazole is usually twice daily for Barrett's oesophagus.  This may be beneficial for patient's who have a tendency to forget to take multiple doses, but otherwise the effect and end points are the same.  One is not more effective than the other. In theory, the PPI known as Esomeprazole is more chemically active.  When first released onto the market, it was suggested to be superior in that smaller doses could be used and that healing times would be reduced.  In my experience, however, this hasn't seemed to be the case.  I regard all PPI equally in their efficacy.  

The issue of cancer with PPIs is somewhat controversial.  The link has been difficult to prove given the presence of other cancer-related risk factors amongst many patients.  Theoretically, by altering the natural environment of the stomach, particularly over a long period of time, the drugs may indirectly cause abnormal cell growth.  And have also been implicated in various intestinal infections (since micro-organisms introduced orally are mostly killed in the acidic conditions of the stomach).  I do not believe one PPI is more problematic than another.  It is a theoretical risk that is shared amongst the entire drug class.  From my understanding, I would say that the PPIs share a similar side effect profile in general.  You may come across some product literature that is more comprehensive than others, but note that pharmaceutical companies publish various types of leaflets, each targeting a different audience.  Some are more 'tame' than others.  

Lastly, a word about long-term PPIs.  The general rule for all medications is to 'use the smallest dose, for the shortest possible time'.  This rule is subjective.  It is dependent upon the patient's clinical presentation.  The shortest possible time may mean life-long in certain groups ...and this is just how it has to be to ensure the patient's condition is managed effectively.  Patients need to be monitored and side effects managed accordingly.  Yes, there are theoretical risks of cancer with PPIs, but patients will often require long term treatment.  They just get assessed periodically.  In my experience, patient's with Barrett's are on long-term (even life-long) PPIs.  It is important for your husband to maintain a good relationship with his gastroenterologist and have regular gastroscopies.  Remember that there is also an increased risk of cancer with Barrett's itself (even without the association of PPIs) due to changes in cellular structure.  So, it is essential to be monitored on a regular basis.  

In summary, Maria, there is no difference between the PPIs.  If the physician wishes to give pantoprazole a go, then your husband should not be afraid to try it.  There may be some variation in individual patient response to PPIs.  See how it goes. Ultimately, it would be prudent to continue being monitored by a gastroenterologist.  

I wish you and your husband all the very best, Maria.  

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Gisella Campanelli

Expertise

I am able to answer questions relating to pharmaceuticals, therapeutic regimes and primary health care. This includes offering advice on drug indications, dosages, and disease state management. I can also identify side effects, drug interactions and contra-indications, and offer recommendations on ways to mitigate these. I can diagnose minor illnesses and suggest appropriate over-the-counter remedies and/or preventive healthcare tips. I can recognize cardinal symptoms which would otherwise require referral to a medical practitioner.

Experience

I am a registered pharmacist in Australia, and I have practiced in a hospital pharmacy for over thirteen years. My clinical specializations lie within the areas of psychiatry and general medicine (including gastroenterology, respiratory, endocrinology, neurology, infectious diseases, gerontology, dermatology). I self-managed the training program for pharmacy interns in preparation for their final registration exams, and I have worked for the Pharmacy Board of Australia as an examiner and exam writer.

Education/Credentials
I hold a Bachelor of Pharmacy from the Victorian College of Pharmacy, Monash University, and I am board-registered to practice within Australia. I also hold a Master's degree in an unrelated field (art conservation).

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