Proton-pump inhibitors (PPIs) like esomeprazole (Nexium), pantoprazole (Protonix), omeprazole (Prilosec) and lansoprazole (Prevacid) are commonly used to treat acid reflux (GERD), acid regurgitation and heartburn. They all work the same way and prevent parietal cells in the stomach lining from secreting acid. They also work just as well in terms of resolving symptoms and healing esophagitis (inflammation of the esophagus).
Also, generally speaking, potential adverse effects of PPIs like risk of fractures, pneumonia, Clostridium difficile (“C. diff”) diarrhea, low magnesium and vitamin B12 deficiency are the same across the board.
So what are some differences in these popular medications?
1) Oral bioavailability
The amount of medication that reaches your system after you take it is its “oral bioavailability.” Think of IV medications—medications placed directly into the bloodstream—as having 100% bioavailability. The oral bioavailability of PPIs can vary depending on the medication and whether you are fasting or not.
Some PPIs have great bioavailability—like lansoprazole and esomeprazole, which can reach oral bioavailabilities of 85% and 90%, respectively. Others have lower oral bioavailability, like rabeprazole (Aciphex) at 52%. For omeprazole and esomeprazole, the fraction that reaches the bloodstream is higher after multiple doses.
2) How quickly they work
Think of this as the time it takes to reach peak effectiveness. Omeprazole (Prilosec) has the fastest time at 30 minutes. Dexlansoprazole (Dexilant), esomeprazole (Nexium) and lansoprazole (Prevacid) are next at about one to two hours. And then for pantoprazole (Protonix) and rabeprazole (Aciphex), the time to peak is slightly longer than that.
3) How long they stay in your system
The half-life of a medication is the time it takes for its concentration in the body to drop by half. It’s often a measure of how long a medication stays active before the body eliminates it as metabolic waste. With PPIs, however, it’s important to know that because they bind so strongly to parietal cells in the stomach lining, they stay active for longer than you’d expect given their measured half-lives below.
Half-lives vary with each PPI. Esomeprazole (Nexium) and omeprazole (Prilosec) have the longest half-lives at almost three hours, and lansoprazole (Prevacid), dexlansoprazole (Dexilant), pantoprazole (Protonix) and rabeprazole (Aciphex) have shorter half-lives at about one to two hours.
4) When you can take them
Unlike Dexilant, taking lansoprazole, esomeprazole, or omeprazole with food in your stomach will decrease the amount of the medication you absorb by half. Take these on an empty stomach before the first meal of the day or they won’t work very well.
Dexilant is an expensive brand-name PPI that will cost you the most, but it stands out for one thing: you absorb this medication to the same extent whether take it on an empty stomach or after a meal.
6) Abdominal issues
Another good thing about Dexilant? It might cause you fewer gastrointestinal problems. Diarrhea and abdominal distension are common side effects reported with fairly equal frequency among all PPIs except for Dexilant, which is less frequently associated with abdominal complaints.
7) Alternatives to pills
Most PPIs come as pills or capsules, but for patients who have trouble swallowing them, lansoprazole is available as a liquid suspension and Prilosec comes in a powdered formulation.
8) Whether they are safe during pregnancy
Most PPIs are categorized as “Class B” by the FDA for usage in pregnancy. This means that although there are no adequate and well-controlled studies to evaluate safety, there have been no animal studies demonstrating potential harm to fetuses.
There are two exceptions here. Omeprazole (Prilosec) has shown some potential fetal toxicity in animal studies, so it’s categorized as “Class C”. Then, there is too little evidence to recommend rabeprazole (Aciphex) at all during pregnancy. The rest are fine.
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