How do proton pump inhibitors compare in gastroesophageal reflux disease (GERD)?

In adults who have GERD but either have not had endoscopy, or endoscopy did not find any erosions, esomeprazole, pantoprazole, and rabeprazole appear to work equally well. [full review] Less evidence exists for preventing relapse, but in one trial where on-demand esomeprazole was compared with daily lansoprazole, fewer patients discontinued esomeprazole. [full review]

In adults with GERD who have erosive esophagitis:

• For complete relief of symptoms at 4 weeks, all PPIs are similarly effective when comparable doses were used. [full review]
• For time to relief of heart burn, all PPIs are similarly effective. [full review]
• For rate of healing at 4 and 8 weeks, no differences were found between omeprazole, lansoprazole, pantoprazole, or rabeprazole. [full review]
• In moderate to severe disease, esomeprazole (40 mg) was more effective at healing esophagitis at 4 and 8 weeks than was either omeprazole (20 mg) or lansoprazole (30 mg). [full review]
• For preventing relapse in adults with healed esophagitis, there was no difference between omeprazole, lansoprazole, and rabeprazole. [full review]

There are no direct comparisons of PPIs for reflux esophagitis in children. [full review]

How do proton pump inhibitors compare in treating ulcers?

For duodenal ulcers, all newer PPIs have been compared to omeprazole and appear to be similar in relieving symptoms and healing.

For gastric ulcers, only rabeprazole (10 mg and 20 mg) has been compared to omeprazole (20 mg). No significant differences were found; only that symptom relief was slightly better with the higher dose of rabeprazole.

For ulcers caused by H. pylori, all the PPIs share similar rates of eradicating this bacterium.

Less evidence is available for ulcers caused by NSAIDs. In relieving symptoms and healing, omeprazole and lansoprazole appear to share similar rates with ranitidine (a histamine antagonist). For prevention in patients regularly taking NSAIDs, no differences were found between pantoprazole (20 mg, 40 mg) and omeprazole (20 mg). [full review]

Does the dose of the proton pump inhibitor influence outcome?

When higher and lower doses of the same drug were compared in adults with GERD, the time in remission was longer when higher doses of omeprazole and rabeprazole were used. The time in remission remained the same for either dose of lansoprazole, and the evidence for esomeprazole is inconclusive.

Using endoscopy to check for remission showed the rates of remission were greater with the higher dose rabeprazole, but there was no difference between either dose of omeprazole and lansoprazole.

In general, a higher rate of relapse of symptoms was linked with lower doses of omeprazole, lansoprazole, and rabeprazole.

When daily use of a PPI was compared with taking PPI less frequently:

• Daily use was superior to intermittent use (on-demand or 3 days a week) in preventing relapse of esophagitis or recurrence of symptoms in patients with healed erosive esophagitis at 6 months
• Daily PPI was not superior to on-demand use in patients with non-erosive esophagitis in terms of the severity of symptoms or relapse

Daily PPI is superior to daily ranitidine in preventing relapse of erosive esophagitis or symptoms of GERD. [full review]

How do proton pump inhibitors compare in safety?

In the short term, there does not appear to be a difference between the PPIs in the rate of adverse events. Limited evidence is available for the longer term, but again suggests there is no difference. [full review]

Does age, gender or race influence the safety or effectiveness of proton pump inhibitors?

Data are limited, but suggest that there is no difference in adverse events in adults of different ages, gender, and race. [full review]

Similarly, not enough data are available to know whether these patient factors influence effectiveness. [full review] One study found that older adults with erosive esophagitis responded better to pantoprazole 40 mg or rabeprazole 20 mg (improved healing rate at 8 weeks) compared to omeprazole 20 mg. [full review]

Drugs included in this review

Further information

This PubMed Clinical Q&A was reviewed by Marian McDonagh, PharmD.

For the full report and evidence tables, please see:
McDonagh MS, Carson S, Thakurta S. Drug Class Review: Proton Pump Inhibitors: Final Report Update 5 [Internet]. Portland (OR): Oregon Health & Science University; 2009 May. Available at: http://www.ncbi.nlm.nih.gov/books/NBK47260/.