PPIs suppress gastric acid secretion by inhibiting the hydrogen-potassium adenosine triphosphatase enzyme system on the secretory surface of the gastric parietal cells. That blocks the final step of acid production and lowers hydrochloric acid in the stomach lumen.
Proton Pump Inhibitors: Generic and Brand Names
- dexlansoprazole (Kapidex)
- esomeprazole (Nexium)
- lansoprazole (Prevacid)
- omeprazole (Prilosec)
- pantoprazole (Protonix)
- rabeprazole (Aciphex)
Disease Spotlight: Gastroesophageal Reflux
GERD is stomach acid flowing back up the esophagus, mild reflux at least twice a week or moderate to severe reflux at least once a week. Typical presentation: burning in the chest (heartburn) after eating and often worse at night, chest pain, difficulty swallowing, regurgitation of food or sour liquid, and the sensation of a lump in the throat.
Indications
Treatment and maintenance of erosive esophagitis and heartburn associated with GERD; GERD, severe erosive esophagitis, duodenal ulcers, and pathological hypersecretory conditions; gastric ulcer; maintenance therapy for healing duodenal ulcers and esophagitis; combination therapy to eradicate Helicobacter pylori; and, in children, GERD, peptic ulcer, and Zollinger-Ellison syndrome.
Pharmacokinetics
Esomeprazole, lansoprazole, and pantoprazole come in delayed-release oral forms and IV preparations. Rabeprazole, dexlansoprazole, and omeprazole come only in delayed-release oral forms.
Contraindications and Cautions
Contraindicated with a known allergy to the drug or its components. Use caution in pregnancy and lactation for potential effects on the fetus or neonate. Safety and efficacy are not established under 18 years of age, except lansoprazole, which is the PPI of choice when a child needs one.
Adverse Effects
CNS: headache, dizziness, vertigo, insomnia. Skin: rash. GI: diarrhea, abdominal pain, nausea, vomiting. Respiratory: upper respiratory infections, cough.
Interactions
Benzodiazepines, phenytoin, and warfarin: risk of increased serum levels and increased toxicity, so monitor closely. Ketoconazole and theophylline: decreased levels and loss of effectiveness. Sucralfate: poorly absorbed in the presence of a PPI, so space doses at least 30 minutes apart. Clopidogrel: omeprazole and esomeprazole inhibit CYP2C19 and cut the antiplatelet effect of clopidogrel by roughly half, so the FDA says to avoid using either PPI with clopidogrel and separating the doses in time does not fix it (FDA Plavix label). Pantoprazole, dexlansoprazole, and lansoprazole have much less effect and are the preferred PPIs when a clopidogrel patient needs acid suppression.
Nursing Considerations
Screen for allergy and for pregnancy or lactation, and get a baseline exam: skin for lesions, rash, pruritus, and dryness; neurological orientation, affect, and reflexes; abdomen and bowel pattern; and respiratory rate and rhythm with attention to cough, hoarseness, and epistaxis. Give the drug before meals and have the patient swallow capsules whole, never opened, chewed, or crushed, to preserve effectiveness. Monitor for diarrhea or constipation and start a bowel program as needed. Watch nutritional status; small frequent meals help if GI upset is a problem. Provide safety measures if CNS effects occur. Arrange medical followup if symptoms persist after 4 to 8 weeks, since a serious underlying condition could be the cause. Teach the drug name and dose, the swallow-whole rule, and the adverse effects to report. Evaluate against relief of hyperacidity symptoms and healing of erosive lesions.
Frequently Asked Questions
How do proton pump inhibitors differ from antacids? Antacids neutralize acid that is already in the stomach and relieve symptoms within minutes. PPIs shut acid production down at the source, the gastric proton pump, so they work over days and are not the right choice for instant relief.
Why are PPIs taken before meals and swallowed whole? PPIs work best when they reach the parietal cells before a meal triggers acid production, so they are dosed 30 to 60 minutes before eating. The delayed-release capsules are swallowed whole, never opened, chewed, or crushed, because crushing destroys the enteric coating and the drug's effectiveness (FDA Prilosec label).
Can a patient on clopidogrel take a PPI? Not omeprazole or esomeprazole. Both inhibit CYP2C19 and cut clopidogrel's antiplatelet effect by about half, and the FDA advises avoiding the combination (FDA Plavix label). Pantoprazole, lansoprazole, and dexlansoprazole are the preferred alternatives.
How do I recognize a PPI by its name? The generic names end in "-prazole": omeprazole, esomeprazole, lansoprazole, dexlansoprazole, pantoprazole, and rabeprazole.
Which PPI is preferred for a child? Lansoprazole is the PPI of choice when a child needs one, since safety and efficacy for the others are generally not established under 18 years of age.
When should a patient on a PPI follow up with a provider? Arrange medical followup if symptoms persist after 4 to 8 weeks of therapy, because a serious underlying condition could be driving the symptoms rather than simple hyperacidity.