Proton pump inhibitors (PPIs): Uses, common brands, and safety info

If you have ever felt an unpleasant burning sensation rising from your chest after a meal, you have likely experienced gastroesophageal reflux (GER), also known as acid reflux. Other symptoms you may have felt are regurgitation of acidic contents into the mouth or throat, nausea, sore throat, hoarseness, and increased saliva production. GER happens once in a while when your stomach contents flow back up into your esophagus.  However, if that uncomfortable feeling happens on a regular basis, then you may have gastroesophageal reflux disease (GERD), which is treated in a variety of ways. 

Usually, your doctor will first recommend some lifestyle changes to improve your symptoms. If those do not work, your provider may also recommend a proton pump inhibitor (PPI). There are six different PPIs, all with similar efficacy, so if you do not respond well to one, you have a number of other options to try. Continue reading to learn more about the various proton pump inhibitors on the market, their uses, brand names, and safety information.

* available in prescription and OTC formulations

What are proton pump inhibitors?

 Proton pump inhibitors are popular medications most commonly used to treat GERD and its complications, such as peptic stricture and Barrett’s esophagus. PPIs are also used to treat ulcer conditions such as Helicobacter pylori (H. pylori) infections and ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs). This class of medications is also used to manage heavy acid production in certain types of stomach tumors. Some PPIs can be found over-the-counter, while others require a prescription. Regardless, proton pump inhibitors are widely used medications for acid-related conditions. In fact, because of their abundance and effectiveness, proton pump inhibitors are frequently overused for longer than their recommended course of therapy. To ensure you are taking your medication for the correct length of time, make sure to discuss this with your pharmacist or healthcare provider.      

How do proton pump inhibitors work?

Proton pump inhibitors work by binding to and inactivating the H+/K+-ATPase, which is a pump that is responsible for secreting acid into the stomach. Because conditions like GERD and peptic ulcers are worsened by stomach acid, inhibiting the amount of acid secretion in your body not only treats the heartburn, indigestion, and abdominal pain associated with GERD, but can also help heal the esophageal lining if it has been affected by acid erosion.  

Lifestyle modifications such as weight loss (if you are overweight or recently gained weight), elevating the head of the bed, avoiding high fat meals within 2-3 hours of sleeping, and staying away from acidic foods and drinks all help in alleviating GERD. Your provider may also recommend antacids or another class of drugs called H2-blockers to help treat your GERD.

What are proton pump inhibitors used for?

Indications depend on the specific drug. Examples include:

• Heartburn

• GERD

• Dyspepsia (Indigestion)

• Erosive and non-erosive esophagitis

• H.Pylori- associated ulcers

• NSAID-associated ulcers

• Gastric and duodenal ulcers

• Prevention of rebleeding of peptic ulcers

• Non-ulcer dyspepsia

• Prevention of stress-related mucosal bleeding

• Gastrinomas 

• Zollinger-Ellison syndrome

Who can take proton pump inhibitors?

Adults

Proton pump inhibitors are generally very safe and effective in adult men and women. While there are some adverse effects and warnings for this class of medications, using the lowest necessary dose and not exceeding the recommended length of therapy usually results in low rates of serious effects.  

Infants and Children

Proton pump inhibitors are approved for use in children over 1-year of age and are dosed based on weight. Use of PPIs in children may result in an increased risk of infections like pneumonia and a stomach infection caused by the organism C. difficile. Proton pump inhibitors may also increase the risk of fractures in children. Therefore, these medications are not generally given to children unless first consulting with a healthcare provider. Infants with symptoms of GERD may be prescribed a  compounded PPI suspension. However, because use of a proton pump inhibitor in infants is not approved by the U.S. Food and Drug Administration (FDA), it is up to the discretion of your healthcare provider to decide the need. 

Seniors

Because long-term use of PPIs can increase the risk of C. difficile infection, bone loss, and fractures, they are not recommended for prolonged use in seniors. In fact, the Beers List of potentially inappropriate medications for older adults recommends no more than eight weeks of continued use in adults over the age of 65. 

Are proton pump inhibitors safe?

Proton Pump Inhibitors Recalls

Auromedics Pharma LLC: Voluntary recall of pantoprazole 40mg for Injection due to presence of glass particles in the vial, December 2017

Proton pump inhibitor restrictions

Do not take proton pump inhibitors if you have a history of a hypersensitivity reaction to any proton pump inhibitor.

Except for esomeprazole, proton pump inhibitors should be avoided in patients who are also taking products containing rilpivirine.

Other warnings include:

• Due to the acid suppression of proton pump inhibitors, rebound acidity may occur after suddenly stopping one of these medications. If you are trying to discontinue your PPI, it is recommended to slowly taper down the dose, even after a short treatment period of 8 weeks. 

• In rare cases, reversible kidney disease has been observed in patients taking PPIs. This is called tubulointerstitial nephritis and is usually presents with symptoms ranging from an allergic reaction (fever, rash, shortness of breath) to more kidney specific reactions (anorexia, malaise, nausea). If these symptoms occur, the proton pump inhibitor should be discontinued and medical help sought immediately.

• Long-term use (2 years or more) can result in decreased vitamin B12 absorption and eventually, B12 deficiency. Since B12 is a crucial vitamin for the body, it is important to monitor levels or supplement this vitamin if you have been taking a proton pump inhibitor for more than two years.

• Gastric acid can be bothersome when it is not confined to the stomach. However, in the stomach, this acidity is important for keeping levels of good and bad bacteria in check. Because proton pump inhibitors suppress stomach acidity, prolonged use may result in an overpopulation of bad bacteria, namely C. difficile. C. difficile is an infection that causes severe diarrhea, dehydration, and serious complications if not treated. Therefore, it is best to use the lowest dose and shortest duration of proton pump inhibitor therapy, especially in the more susceptible elderly population.

• Long-term use of proton pump inhibitors has been shown to increase the risk of osteoporosis and bone fractures. If you are on high-dose or long-term PPI therapy, you should be routinely monitored for bone health. Some providers may even encourage supplementation with calcium or vitamin D while taking a proton pump inhibitor.

• Rarely, using a proton pump inhibitor for more than three months has resulted in a decrease in magnesium levels. More serious cases may involve seizures or feelings of irregular heartbeats. If you are also taking a diuretic, digoxin, or another medication that may cause hypomagnesemia, your provider may take an initial reading of your magnesium levels to keep track.

• Another rare side effect associated with long-term proton pump inhibitor use is an autoimmune disease called lupus. Generally, if lupus occurs while using a PPI, it shows as rashes or lesions on areas of the skin that receive the most sun and is known as cutaneous lupus. Sometimes there can be a reaction involving the entire body, which presents with joint pain, rashes, extreme fatigue, and low fevers. The body-wide reaction, called systemic lupus, may occur within just a few days of using a proton pump inhibitor. Fortunately, lupus that results from using a proton pump inhibitor usually resolves within 1-3 months of stopping the medication.

• Proton pump inhibitors may decrease the effectiveness of clopidogrel, a drug used to prevent blood clots. This occurs because PPIs inhibit an enzyme called CYP2C19, which is important for changing clopidogrel to its active form. Because of this potential drug interaction, it is necessary to inform your doctor before starting a PPI if you are already taking clopidogrel or vice versa.

Can you take proton pump inhibitors while pregnant or breastfeeding?

Pregnant women should first attempt lifestyle changes to address GERD and consult with their doctors before taking a PPI. Because small amounts of these drugs can pass into breast milk, nursing mothers should talk to their healthcare providers before using a proton pump inhibitor.

Are proton pump inhibitors controlled substances?

No, proton pump inhibitors are not controlled substances.

Common proton pump inhibitors side effects

Proton pump inhibitors are generally well-tolerated. However, there are some common side effects that may occur, such as headache, constipation, diarrhea, and upset stomach. 

More serious side effects that require immediate medical attention are as follows:

• Signs of an allergic reaction (rash, hives, difficulty breathing or swallowing, or swelling of the lips, throat, or mouth)

• Signs of low magnesium levels (mood changes, muscle pain or weakness, cramps, shakiness, seizures, abnormal heartbeat)

• Changes in kidney function (inability to pass urine, blood in urine, or sudden weight gain)

• Dizziness or passing out

• Numbness or tingling in hands and feet

• Bone pain

• Stomach cramps, very loose stools, diarrhea

• A severe skin reaction may occur called Stevens-Johnson syndrome. Although rare, it is a serious reaction. Seek immediate medical help if you experience red, swollen, blistered, or peeling skin, or sores in your mouth, throat, nose, or eyes. 

How much do proton pump inhibitors cost?

Proton pump inhibitors are available in OTC and prescription form. OTC versions such as esomeprazole and lansoprazole usually cost no more than $30 at your local pharmacy. Prescription proton pump inhibitors tend to be higher in price, averaging more than $100 for a month’s supply if uninsured. For example, omeprazole is the first PPI to be introduced to the market, but still averages more than $50 a month without insurance. A coupon from SingleCare may lower the cost of omeprazole so that you pay less than $10 at participating pharmacies. Your insurance may have preferences on which proton pump inhibitors they will cover, so if your choice is not on the formulary, always check with SingleCare to ensure that you are paying the best price.