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CONTINUING PROFESSIONAL DEVELOPMENT
Proton pump inhibitors
BY ANGUS THOMPSON
Since omeprazole was launched early in the 1990s, the proton pump
inhibitors (PPIs) have revolutionised the management of upper
gastrointestinal (GI) disorders.
Whilst the foundation for this
transformation was laid by the
histamine-2 antagonists a decade
earlier, the superior efficacy of the PPIs
and their generally excellent tolerability
has seen them become one of the
most commonly prescribed drugs.
Recognising the size of the potential
market, other manufacturers soon
introduced ‘me-too’ PPIs to compete
with omeprazole and shortly before the
expiry of the patent on omeprazole, the
S-isomer of the parent compound was
launched, and esomeprazole brought
the number of PPIs available in Australia
Clinical indications for PPIs
PPIs are most commonly used for
managing gastro-oesophageal reflux
disease (GORD), peptic ulcer disease
and non-ulcer dyspepsia. There are
a range of other indications for their
use, some of which are approved by
the Therapeutic Goods Administration
(TGA), while others are not. The
range of clinical indications for PPIs is
summarised in Figure 1.
TGA-approved clinical indications for the
individual PPIs also vary, especially in
terms of some less common indications.
Nonetheless, in practice many clinicians
apply the principle of ‘class effect’ when
using PPIs, extrapolating the evidence
and experience with one PPI to the
group as a whole.
Whilst the PPIs currently on the
Australian market have many similarities,
there are differences that can influence
the decision regarding which PPI to
prescribe for an individual patient.
Dosing, formulations and
The duration of effect of all five
PPIs means that single daily doses
are generally effective. However, a
twice-daily regimen may be appropriate
when standard doses are insufficient
and is always indicated when being
used to treat H. pylori.
The choice of PPI for some patients
may be influenced by the availability
of formulations that do not require
them to be swallowed whole. Several
PPIs are now available to meet these
particular patient needs. Similarly, for
those acutely unwell patients who
require parenteral therapy, three of the
PPIs are available in a formulation for
All five PPIs are TGA-approved for use in
regimens to eradicate H. pylori. However,
only two are available in a combination
pack alongside the recommended
first-line antibiotics (amoxycillin and
clarithromycin). The complexity of H.
pylori eradication regimens may impact
adversely on compliance and this
increases the risk of treatment failure.
Therefore, preference should be given
to using a combination pack to improve
adherence through convenience, and
reduce the cost to patients, unless there
is a clear indication for using a different
PPI or antibiotic, e.g. where there is an
allergy to penicillin or where recent use
of clarithromycin may have increased
the risk of resistance.
All PPIs inhibit both basal and food-
stimulated secretion of gastric acid
and after a single standard dose these
are typically reduced by around 70%
and 80% respectively. After several
days of repeated dosing, levels of
acid suppression may approach
90%. However, there is some debate
surrounding ‘equivalent’ doses of the
available PPIs and some guidelines
suggest that this is dependent on the
These features of the available PPIs are
summarised in Table 1.
Angus Thompson is a Lecturer in Therapeutics and
Pharmacy Practice at the University of Tasmania and a
consultant pharmacist carrying out HMRs in Southern
After reading this article, pharmacists should be
• Outline factors that may influence choice of
proton pump inhibitor (PPI) therapy
• Discuss potential adverse consequences of PPI
• Recognise appropriate opportunities to optimise
the use of PPI therapy.
Competency standards (2010) addressed: 1.3, 4.1,
4.2, 4.3, 7.1, 7.2 .
Accreditation number: CAP141212E
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