ppisupdate-final.pdf

7/27/2019 PPIsUpdate-FINAL.pdf

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Cntents

2: OurRecommendations

4: Welcome

6: What Are PPIs andWho Needs Them?

8: Choosing a PPIOur Best BuyPicks

14: Tips to TalkingWith Your Doctor

15: How We Picked theBest BuyPPIs

16: Sharing this Report

16: About Us

17: Reerences

Using the Proton Pump Inhibitors to Treat

HeartburnandStmachAcidRefuxCopARgEECvEESS,SAEy,ApRCE


2/18

USIN TH PROTON PUP INHIBITORS TO TRAT: HARTBURN AND STOACH ACID RfUxCoSERREpoRSBESByRgS

2

Proton pump inhibitors (PPIs) are a class o very

eective and generally sae medicines used to treat

heartburn, gastroesophageal reu disease (RD),and gastric ulcers.

But not everyone who eperiences heartburn needs

one. Several o the PPIs have been widely advertised

to consumers and heavily promoted to physicians, and

this has led to an overuse o the drugs in the treatment

o garden-variety heartburn. PPIs are among the

highest-selling classes o drugs in the U.S., with $9.5

billion in sales last year, and one o them, Neium, was

the top-selling o all drugs, earning nearly $6 billion in

2012, according to IS Health, which tracks drug salesand marketing.

I you suer rom occasional heartburn and have not

been diagnosed with RD, nonprescription antacids

such as aalo, ylanta, Rolaids, and Tums, or

acid-reducing drugs known as H2 blockers, such as

cimetidine (Tagamet), amotidine (Pepcid), nizatidine

(Aid), and ranitidine (Zantac) will very likely provide

relie. All o those products are available without a

prescription as low-cost generics.

Talk with your doctor about the role that dietary and

liestyle changes can play in alleviating heartburn,

too, such as eating smaller meals and not lying down

or at least three hours ater eating, losing weight i

you need to, and avoiding alcohol. I, however, you

eperience heartburn twice a week or more or weeks

or months on end, have requent regurgitation o ood

into your throat or mouth (with or without heartburn),

or i your heartburn is not relieved by the drugs

mentioned above, you may have RD and may need

a PPI. RD is a condition that makes you prone toacid reu and, over time, can cause damage to your

esophagus.

The seven available PPI medicines

are roughly equal in eectivenessand saety but dier in cost. Three

omeprazole (Prilosec, Prilosec OTC),

lansoprazole (Prevacid, Prevacid

24HR), and omeprazole/sodium

bicarbonate (Zegerid, Zegerid OTC)

are available as both prescription and

nonprescription drugs.

fourlansoprazole, omeprazole, omeprazole/sodium

bicarbonate, and pantoprazole (Protoni)are

available as both brand-name drugs and generics

that contain the same active ingredient but cost

signicantly less.

Taking the evidence or eectiveness, saety, cost,

and other actors into account, i you need a PPI, we

have chosen the ollowing as Consumer Reports Best

Buy Drugs:

eneric omeprazole OTC

eneric lansoprazole OTC

ourRecmmendatins


3/18


3

Both o these drugs are available without a prescription.

You could save $200 a month or more by choosing one

o these medicines over more epensive prescriptionPPIs. I you have health insurance, nd out i your plan

will help pay or generic omeprazole OTC or generic

lansoprazole OTC. I not, talk with your doctor about

taking the PPI with the lowest out-o-pocket cost or

you. I you have esophagitis (inammation o the

esophagus), you might want to consider esomeprazole

(Neium), pantoprazole (Protoni and generic), or

rabeprazole (AcipHe). Some research suggests those

drugs could provide better healing rom esophagitis.

Safetynote: Several studies have now linked PPIsto a higher risk o pneumonia and inection with

a bacterium called Clostridium difcile, and other

studies have ound that long-term use o PPIs may

be associated with an increased risk o ractures. Talk

with your doctor about those risks, especially i you

must take a PPI over a long period o time. People

who are 65 and older and those with chronic medical

conditions should be vaccinated against pneumonia

and get a u shot every year. And we emphasize this

recommendation or people in those categories who

are also taking a PPI.

In addition, anyone taking clopidogrel (Plavi and

generic), a blood thinner used to prevent clots ater

heart attacks and stent placement, should be especiallycautious with PPIs, particularly omeprazole and

esomeprazole because they can reduce clopidogrels

eectiveness, which could increase the risk o another

heart attack. Our medical advisers recommend that

people taking clopidogrel should not take PPIs unless

other treatments have not been adequate.

This report was updated in July 2013.

ourRecmmendatins


4/18


4

Proton pump inhibitors (PPIs) are a class o drugs

used to treat heartburn, gastroesophageal reu

disease (RD), and gastric ulcers.

Heartburn and RD are quite common. Heartburn

is the main symptom o RD but does not always

signal it (see page 6 or a more detailed eplanation).

Between a quarter and a third o adults in the U.S.

will have RD symptoms at some point. It is most

common among people ages 50 and older but can

strike at any age. Pregnant women are also highly

prone to RD.

This evaluation o PPIs is part o a Consumer Reportsproject to help guide you to medicines that are most

eective and sae, and give you the best value or your

health-care dollar. To learn more about the project

and the other classes o drugs we eamine, go to

www.CRBestBuyDrugs.org.

Si PPIs and one combination drug are currently

available. They are listed below.

Delansoprazole (Deilant) was approved by the fDA

in January 2009 (The brand name was changed rom

Kapide to Deilant in 2010 because the previous

name was sometimes conused with other medications

that had similar names). Because ew studies have

been done using Deilant, less is known about its

eectiveness. In addition, its saety prole is not ully

established yet. for those reasons, we recommendsticking with the other PPIs, especially our Best Buy

picks, until more is known about this drug.

Welcme

generic ameBrand Aailableasa

prescritin

genericru?

Aailableasa

nrescritin

ru?

someprazole Neium No No

Delansoprazole Deilant No No

ansoprazole Prevacid, Prevacid 24HR(a nonprescription version)

Yes Yes

Omeprazole Prilosec, Prilosec OTC Yes Yes

Omeprazole/Sodium Bicarbonate

Zegerid, Zegerid OTC Yes Yes (brand name only)

Pantoprazole Protoni Yes No

Rabeprazole AcipHe No No


5/18


5

four PPIslansoprazole, omeprazole (Prilosec),

omeprazole/sodium bicarbonate (Zegerid), and

pantoprazole (Protoni)are available as genericprescription drugs. Three o the PPIs are available

over-the-counter without a prescriptionlansoprazole

(Prevacid 24HR and generics), omeprazole (Prilosec

OTC and generics), and omeprazole/sodium

bicarbonate (Zegerid OTC). The cost or those

nonprescription medications is signicantly lower than

the prescription versions, i you are paying out-o-

pocket. None o the available studies on Zegerid met

the criteria or inclusion in the scientic analysis that

orms the basis o this Best Buy Drugs report.

Other prescription and nonprescription medicines are

available to treat heartburn and acid reu. Among

them are the over-the-counter antacids aalo,

ylanta, Rolaids, and Tums, all o which are available

as generics. These medicines work within minutes

to relieve heartburn and acid indigestion. But their

eect lasts only a ew hours.

Another class o drugs, called H2 blockers, is also

available over-the-counter to treat mild, occasional

heartburn and ecess stomach acidity. Thenonprescription versions o drugs in this class include

cimetidine (Tagamet OTC), amotidine (Pepcid AC),

nizatidine (Aid AR), and ranitidine (Zantac 75, Zantac

150), all o which are available as low-cost generics.

H2 blockers take longer to work than antacids30

minutes to an hourbut they provide heartburn relie

or up to 12 hours.

Stronger doses o H2 blockers are also available

by prescription, and all are also available as lower-

cost generics.

Studies have ound that PPIs reduce

stomach acid more over time thanantacids or H2 blockers. But PPIs

are not intended or the immediate

relie o heartburn. Antacids and H2

blockers actually do a better job at

that. The main advantage o treatment

with PPIs, in addition to reducing

stomach acid or longer periods

o time, is that they treat people

diagnosed with RD or ulcers.

This report evaluates only PPIs, which have become

the most widely prescribed medicines in the U.S.

to treat heartburn and RD when symptoms persist,

are chronic or severe, or are unrelieved by antacids

or H2 blockers.

This report was published in July 2013.

Welcme


6/18


6

WhatAreppsand

Wheedshem?

PPIs work by blocking an enzyme that is necessaryor making acid in the stomach. When this enzyme is

blocked, acid production decreases.

PPIs are very eective and relatively sae. But not

everyone needs one. Several o them have been widely

advertised to the public and promoted to physicians

particularly Neium (the purple pill), which earned

nearly $6 billion in sales in 2012, making it the top

seller among all medications, according to IS Health.

any physicians think the heavy promotion has led

to an overuse o PPIs in the treatment o occasionalheartburn. figures rom IS Health show the number

o prescriptions written in the U.S. or PPIs in 2012

topped 127 million, making them among the most

commonly prescribed class o drugs.

Beore you start taking a PPI, we advise

talking with your doctor about other

medicines that may be useul i you

have only occasional heartburn (oncea week or less) and have not been

diagnosed with RD.

Also, talk with your doctor about the role that dietary

and liestyle changes can play in alleviating heartburn,

such as eating smaller meals and not lying down or at

least three hours ater eating, losing weight i you need

to, and avoiding alcohol.

Almost everyone has heartburn once in a whileoreample, ater a heavy or spicy meal, or ater drinking

alcohol. Heartburn is an uncomortable sensation that

usually starts just below your breastbone and can

radiate into your throat. You may also get a sour or bitter

taste in your mouth or throat.

Occasional heartburn is not worrisome or dangerous,and can be largely relieved by taking over-the-counter

antacids or H2 blockers. ven i you have a period

o timesay a couple o weeksin which you get

heartburn airly regularly, you may not need anything

stronger than those drugs.

However, i you have heartburn at least twice a

week or weeks or months on end, have requent

regurgitation o ood into your throat or mouth (with or

without heartburn), or i your heartburn is not relieved

by antacids or H2 blockers, you may have RD.

RD (gastroesophageal reu disease) is not just the

result o requent heartburn or ecessive eating, as

commonly thought. Its caused by a physical condition

that many people appear prone to, when the ring o

muscle between the esophagus and stomach doesnt

work properly. The muscle usually opens when ood is

passing through on its way to the stomach. In people

with RD, however, the muscle seems to open at

other times. Or it stays open too long ater ood has

passed through. When either happens, acid rom thestomach can ow back up into the esophagus. This is

called acid reu.

There are no denitive studies o how many Americans

actually have RD. By some estimates, more than

60 million eperience heartburn at least once a month

and 15 million suer rom it daily. So it is possible

that tens o millions o people may have the condition.

The bottom line is that i you have heartburn twice a

week or more you could meet the criteria or RD

and should see a doctor i your symptoms are notcontrolled by liestyle changes, over-the-counter

antacids, or H2 blockers.


7/18


7

WhatAreppsand

Wheedshem?

In contrast to occasional heartburn, RD can bedangerous. I it isnt treated, over time, the acid reu

can iname or erode the lining o the esophagus, a

condition called esophagitis. You may sense it as a

chronic soreness in your lower throat and/or chest.

ost cases o esophagitis are relatively mild. But i

let untreated, it can result in bleeding, scarring, and a

narrowing o the esophagus. This can make eating and

swallowing oods painul and dicult. People who have

uncontrolled RD or years also have a higher risk o

cancer o the esophagus, though this cancer is rare.

Between a third and hal o the people with RD will

have some damage to their esophagus, although its

usually mild. But doctors cant tell who is going to

develop that damage and who will not, or how severe it

might be. As a result, i you are diagnosed with RD,

your doctor will almost certainly prescribe a PPI. All

o these drugs greatly reduce the amount o acid your

stomach produces, making the reuing stomach

contents less erosive. That allows the esophagus to heal.

I you are diagnosed with RD, your doctor mayalso recommend that you undergo a procedure called

an upper endoscopy. The procedure uses a lighted

eible tube, put down the throat, to look inside the

esophagus. Your doctor will then look or damage to

your esophagus. He or she may also take a sample o

tissue to test or cancer.

PPIs dont cure RD; they treat the symptoms. Not a

lot is known about how people with RD do over the

long-term. But it appears that some have RD or lie

while or most, the condition occurs only sometimes orresolves on its own.

I you are diagnosed with RD and are given a

prescription or a PPI, talk with your doctor about how

long you should take the medicine. Ater a ew months,

you may be able to stop taking it without any problems.

I your symptoms return, you can oten start takingthe medicine again. any doctors and pharmacists

think that PPIs are overused to treat people who have

heartburn but do not have signs o esophagitis.

A small number o people who have severe symptoms

and/or are prone to severe damage to their esophagus

may need to take a PPI every day or years. People

diagnosed with RD should have dietary counseling

to determine which oods may worsen their symptoms.

Quitting smoking is also recommended. And i you are

overweight, research has shown that losing weight canreduce heartburn and RD.

PPIs are also used to treat peptic ulcers, erosions in

the lining o the stomach or upper intestinal tract.

These ulcers are caused primarily by a bacterial

inection with an organism called Helicobacter pylori.

PPI drug treatment alone does not eliminate the

inection; you need antibiotics or that. The benet o

using PPIs is that they enable the ulcers to heal by

reducing stomach acid. That treatment has virtuallyeliminated the need or ulcer surgery ecept or those

in whom bleeding is unstoppable.

PPIs are also now commonly prescribed to help

prevent or treat erosions in the stomach lining in

people who take nonsteroidal anti-inammatory drugs

(NSAIDs), such as ibuproen (Advil and generics) or

naproen (Aleve and generics), or corticosteroids such

as prednisone to treat arthritis or pain. Studies have

ound that they help by reducing stomach acid and

allowing the ulcers to heal. People who take NSAIDsregularly or pain, arthritis, or other reasons should

talk with their doctor about taking a PPI as well to

protect their stomach.

In this report, we only evaluate PPIs or treating

heartburn and RD.


8/18


8

Chsinapp

ourBestBuypicks

All PPIs are highly eective at reducing stomach acid,relieving heartburn, and thereby helping to heal damage

to the esophagus caused by RD. The overall evidence

rom research that compared the drugs with each

other shows them to be very similar, with no PPI any

better than any other. Some studies have indicated that

esomeprazole (Neium) may have a slight advantage,

but the drug was administered at a higher dose in these

trials (we discuss this in more detail on page 13).

As you can see in Table 1, below, i you take a PPI

you have a 65 to 77 percent chance o completesymptom relie ater our weeks. You have a 77 to 90

percent chance that any damage that occurred to your

esophagus will be healed ater eight weeks. And the

majority o people who are advised to remain on a PPI

to prevent relapses dont usually eperience one. Someresearch indicates pantoprazole and rabeprazole provide

better symptom relie and healing o esophagitis at eight

weeks, and that esomeprazole provides better esophagus

healing (inammation has gone away) over 6 months.

The gures in Table 1, below, are compiled rom many

studies, so they do not reect a direct comparison o

the PPI drugs as i the drugs were evaluated against

each other in a single study. The gures are presented

here to illustrate the general eectiveness o the class

o PPIs. The dierences between the drugs should notbe taken as an indication that one drug is stronger or

weaker, or better or worse, than any other. That is one

reason we give you the ranges o response as well as

the averages.

able1.generalEectienesspps1

genericameAnd

sepera

Brandame SmtmRelieat

4Weeks,Aerae

percentae

patients(Rane)

EshaealHealin

at8Weeks,Aerae

percentae

patients(Rane)

Relase

preentin,

percentae

patients

Delansoprazole 30 mg Deilant NA2 NA2 75

Delansoprazole 60 mg Deilant NA2 86(82-89) 83

someprazole 20 mg Neium NA2 87 (84-91) 87

someprazole 40 mg Neium 73(65-82) 90(88-92) 93

ansoprazole 30 mg Prevacid 70(61-80) 86 (83-90) 91

Omeprazole 20 mg Prilosec 65 (54-76) 85 (81-88) 86-92

Pantoprazole 20 mg Protoni 77(70-84) 77(65-88) 55-86

Pantoprazole 40 mg Protoni 72(62-83) 89(86-92) 78

Rabeprazole 20 mg AcipHe 69(52-86) 82(76-89) 89

1. ectiveness data presented or PPI dosage strengths that have been studied to date. Data are rom individualstudies included in DRPs analysis o the PPIs. Ranges given reect ndings rom multiple studies.

2. NA=Data not available.


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9

Chsinapp

ourBestBuypicks

Doctors have no way o gauging how a person willrespond to a PPI or i they will respond to one better

than another. The gures we present indicate that most

people can epect to get relie rom taking any PPI.

But its not uncommon or some people to respond

better to one PPI than another. As a result, your doctor

may recommend that you try another PPI i the one

you try initially does not appear to work ater about si

weeks. Or your doctor may prescribe a higher dose o

the PPI beore switching you to another one.

ppsSideEectsandSaet

PPI drugs can cause both minor and serious side

eects, but studies have not ound any signicant

dierences between the PPIs in the side eects they

cause or their saety proles. inor side eects

include headache and diarrhea. About one to three

percent o people stop taking a PPI because they

cannot tolerate the side eects. In light o the potential

risks, the fDA advises doctors and patients to only use

PPIs when necessary and to limit them to the lowestdose or the shortest period required or relie, or that

is appropriate or your condition.

One serious side eect o PPIs includes being

susceptible to certain inections since there is a

decreased production o stomach acid, which normally

helps protect against inections by killing bacteria and

viruses. Specically, taking PPIs can increase the risk

o community-acquired pneumonia, particularly within

the rst month o use. They can also increase the risk

o inection with a bacterium called Clostridium difcile,which can cause disabling diarrhea and high ever and

can lead to more serious intestinal conditions.

You may be at higher risk or inection i you have

asthma, lung disease, decreased immunity (because

o HIV or AIDS, or eample), or are older. People 65

and older are already advised to get vaccinated against

pneumonia and to get a u shot every year. Takinga PPI on a regular basis may be another important

reason to get both vaccines.

In addition, several studies have ound that some

people who took PPIs had a higher risk o hip

ractures, and one study ound an increased risk o

wrist and orearm ractures. The drugs can potentially

interere with the absorption o calcium, which can

lead to weakened bones. The bone ractures occurred

mostly in patients older than 50 who either took high

doses or PPI or stayed on them or one year or longeraccording to an fDA review.

In addition, when taken or longer than a year, PPIs

can lower blood levels o magnesium. Although many

patients dont have symptoms when their magnesium

levels are low, it can be a serious condition leading

to muscle spasms, irregular heartbeat, and seizures.

I you might be on a PPI or a long time or i you are

taking digoin, a diuretic, or any other medication that

can lower your magnesium, your doctor should order

blood tests to monitor your magnesium levels.

runteractinCncerns

PPIs are known to interact with other medicines and

dietary supplements in ways that can be dangerous.

In some cases, your doctor may recommend that you

take a specic PPI because o evidence that it is less

likely to interact with another drug you are taking.

People oten take a PPI to decrease stomach irritationand bleeding that can occur with a blood-thinning

drug called clopidogrel (Plavi or generic)oten

prescribed or patients ater heart attacks, strokes,

stent placements, and other heart problems. But i

you take Plavi, you should be cautious about taking a

PPI, particularly esomeprazole or omeprazole because

they can reduce Plavis protective eect, which could


10/18


10

increase the risk o another heart attack. This issueis important to discuss with your doctor i you take

clopidogrel. Our medical advisers recommend that

people who take Plavi should skip PPIs unless other

treatments have not been adequate.

I you take Plavi and require a medication to treat

your heartburn, RD, or gastric ulcer and your

symptoms arent severe, another option may be an

older class o drugs called H2 blockers, which includes

nizatidine (Aid, Aid AR), amotidine (Pepcid, Pepcid

AC), and ranitidine (Zantac, Zantac 75, Zantac 150). Allare available as low-cost generics. You could also try

an antacid. These drugs have not been associated with

reducing the protective eects o Plavi. You should

also talk to your doctor about having periodic blood

counts or monitoring o your stools in order to detect

gastrointestinal bleeding you may not be aware o

(black, tarry stools can be a sign o this, or eample).

The main drugs to be concerned about potentially

interacting with PPIs are:

Clopidogrel (Plavi and generic), and potentially

other anti-clotting medication, used to prevent

clots ater a heart attack, stroke, and/or stent

placement

Blood thinners, such as wararin (Coumadin

and generics)

Anti-aniety drugs known as benzodiazepines,

such as diazepam (Valium and generics)

Antibiotics

Phenytoin (Dilantin and generics), used to

treat epilepsy

Disuluram (Antabuse and generic), used to

treat alcoholism

Atazanavir (Reyataz) and nelnavir (Viracept),

used to treat HIV/AIDS

Another concern is whether PPIsare sae to take during pregnancy,

because pregnant women are prone to

heartburn and RD. Unortunately,

theres not enough evidence to draw a

rm conclusion about this.

One study ound no increased risk o rates o preterm

birth, miscarriage, ectopic pregnancy, or stillbirth in

women who took PPIs while pregnant, compared to

those who did not. But this study had several limitations

so more studies would be needed to conrm there is no

risk beore a denitive conclusion can be made.

finally, studies indicate that about three percent o

Caucasians and Arican-Americans and 17 to 25 percent

o Asian-Americans have less than average amounts o

the enzymes that break down PPIs in the body. for these

groups o people, less than the usual dose o a PPI might

work just as well to relieve symptoms, though the usual

doses are considered to be sae. Testing to determine a

persons level o this enzyme is not necessary.

CstandourBestBuypicks

While the seven PPIs evaluated in this report do not

dier in eectiveness or saety, they do dier in price.

The average monthly cost ranges rom less than $20

to more than $400 (See Table 2 on page 11.). Taking

the evidence or eectiveness, saety, cost, and otheractors into account, i you need a PPI, we have chosen

the ollowing as Consumer Reports Best Buy Drugs:

eneric omeprazole OTC

eneric lansoprazole OTC

Chsinapp

ourBestBuypicks


11/18


11

able2.ppCstCmarisn

genericame Brand

ameArequenc

seBAerae

nthlCstC

Delansoprazole 30 mg sustained-release tablets Deilant One per day $188

Delansoprazole 60 mg sustained-release tablets Deilant One per day $183

someprazole 20 mg capsules Neium One per day $240

someprazole 40 mg capsules Neium One per day $234

ansoprazole 20 mg delayed-release tablets (nonprescription) Prevacid 24HR One per day $24D

ansoprazole 20 mg delayed-release tablets (nonprescription) eneric One per day $17D

ansoprazole 15 mg delayed-release capsules Prevacid One per day $265

ansoprazole 15 mg delayed-release capsules eneric One per day $119

ansoprazole 15 mg delayed-release dissolvable tablets Prevacid One per day $285

ansoprazole 15 mg delayed-release dissolvable tablets eneric One per day $161

ansoprazole 30 mg delayed-release capsules Prevacid One per day $275

ansoprazole 30 mg delayed-release capsules eneric One per day $107

ansoprazole 30 mg delayed-release dissolvable tablets Prevacid One per day $265

ansoprazole 30 mg delayed-release dissolvable tablets eneric One per day $163

Omeprazole 20 mg tablets (nonprescription) Prilosec OTC One per day $22D

Omeprazole 20 mg tablets (nonprescription) eneric One per day $17D

Omeprazole 10 mg delayed-release capsules Prilosec One per day $211

Omeprazole 10 mg delayed-release capsules eneric One per day $64





Chsinapp

ourBestBuypicks


12/18

Uig t Pt PUP iibit t tt: tbU d tc cid flUxCm p B B D

12

these are proven menes avaae whou a

presrpon. for mos peope, hey are as eeve ashe more epensve presrpon aernaves. ess

han $1 a ay, ener omeprazoe tc an ener

ansoprazoe tc os one-enh he pre o severa o

he presrpon aernaves, a major savns or hose

who nee a PPi.

houh Zeer tc aso oss aou he same as

he oher over-he-ouner PPisaou $20 or a

monhs suppywe an ye reommen eause

he avaae sues on Zeer no mee he

rera or nuson n he sen anayss haorms he ass o hs Best Buy Drugs repor, so we

on know how ompares n erms o eeveness

an saey.

ur hoe o hese over-he-ouner menes

presens wo quesons, however. the rs s: do younee o vs a oor you sar akn one o hem

or hearurn an hnk you may have gd? the

answer s yes. buyn hese rus o reeve oasona

hearurn requres no na physan vs, savn you

ha roue an epense. bu you have perssen

hearurnwe a week or severa weeksor you

have soreness n your hroa or hes, you shou see

a oor as soon as posse, even as you onnue

o ake he over-he-ouner PPis or any oher

nonpresrpon a reuer. ememer, gd an

e anerous an you an anose yourse.

Choosing a ppI

ur Best Buypicks

able 2. ppI Cost Coarison (continued)

eneric ae Brand

aeAFrequency

of seBAverage

monthly CostC

Panoprazoe 20 m eaye-reease aes Proon ne per ay $254

Panoprazoe 20 m eaye-reease aes gener ne per ay $70

Panoprazoe 40 m eaye-reease aes Proon ne per ay $232

Panoprazoe 40 m eaye-reease aes gener ne per ay $66

aeprazoe 20 m aes pe ne per ay $355

. gener naes ru so y ener name. mon PPis, omeprazoe, omeprazoe/soumaronae, ansoprazoe, an panoprazoe are avaae as ener rus.

b. s ypay presre.c. onhy os rees naonwe rea averae pres or pr 2013, roune o he neares oar. inormaon was erve

y Consumer Reports Best Buy Drugs rom aa prove y oure eahare nays, in., whh s no nvoven our anayss or reommenaons. verae monhy os s ase on reommene osae o one p ay.

d. Pres or hese meaons were oane y consumer epors sere shoppers a ve major han pharmaes(cV, e , tare, Wareens, an Wamar) an oa supermarkes aross he U.. n January 2013. the presrom he varous sores were averae o ye per-p pres, whh were hen onvere no a monhy pre.


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The second question involves your healthinsurance status. Insurers do not typically pay or

nonprescription medicines. So i you have insurance

and your doctor says you need a PPI, he or she may

be inclined to prescribe one rather than tell you to

buy one o the over-the-counter PPIs. Beore that

happens, you should nd out rom your health plan

i it covers over-the-counter PPIs. Some insurers

do, and others may provide coverage under certain

circumstances. I this is the case, youll save money

by starting your treatment with one o the drugs that

doesnt require a prescription.

I your health plan does not oer coverage o an over-

the-counter PPI, you can:

Consult with your doctor to choose the PPI that

has the lowest out-o-pocket cost under your

insurance plan. eneric prescription omeprazole,

or eample, may be available or a copayment o

$5 to $10 a month.

Pay or an over-the-counter PPI instead o out o

your own pocket.

ither way, your monthly cost will be relatively low, and

the dierence in cost between the two choices may be

quite small. Choosing nonprescription omeprazole OTC

or generic lansoprazole OTC oers the convenience o

purchasing more without a doctors prescription. And

i your symptoms ease or disappear, you may not need

to visit the doctor again.

I you do not have health insurance or prescription

drug coverage, or you must pay a sizable portion odrug costs out-o-pocket, nonprescription omeprazole

or lansoprazole are the clear drugs o choice. These

will save you substantial amounts o money.

I you have RD and have moderate to severesymptoms or esophagitis, you may need a higher dose

o a PPI. I you take nonprescription omeprazole or

lansoprazole, you could take one to two 20 mg tablets

daily at a cost o around $17 to $34 a month.

In that contet, the makers o Neium have promoted it

heavily as the superior drug to treat people with RD

and esophagitis. The gures we present in Table 1 show

that, on average, Neium may have a slight advantage

over several o the other PPIs or such use. However, the

justication or such a claim seems marginal at best.Neium is usually prescribed at a dose o 40 mg, which

studies have ound to be more potent than, say, 20 mg

o generic omeprazole or Prilosec OTC. Other studies

have ound Neium 40 mg to be equivalent to Protoni

at 40 mg and Prevacid 30 mg. In addition, one key

study ound that people with RD without esophagitis

did just as well with generic omeprazole at 20 mg as

with Neium at 20 mg or 40 mg.

However, i you have been diagnosed with esophagitis,

you might want to consider Neium, pantoprazole(Protoni and generic), or rabeprazole (AcipHe)

because, as we previously noted, some research

suggests they provide better healing rom that

condition. None are available over-the-counter, so

they are all more epensive than our Best Buy picks.

And because there are no generic ormulations o

Neium and AcipHe, they are both substantially more

epensive than generic pantoprazole.

Chsinapp

ourBestBuypicks


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14

Its important or you to know that theinormation we present here is not meant to

substitute or a doctors judgment. But we

hope it will help you and your doctor arrive

at a decision about which PPI and dose is

best or you, i one is warranted at all, and

which gives you the most value or your

health-care dollar.

1.entincstturdctr.Bear in mind that many people are reluctant todiscuss the cost o medicines with their doctor, and

that studies have ound that doctors do not routinely

take price into account when prescribing medicines.

Unless you bring it up, your doctor may assume that

cost is not a actor or you.

2.Askabutldermedicatins.

any people (including physicians) thinkthat newer drugs are better. While thats a natural

assumption to make, its not always true. Studies

consistently nd that many older medicines are as good

as, and in some cases better than, newer medicines.

Think o them as tried and true, particularly when it

comes to their saety record. Newer drugs have not yet

met the test o time, and unepected problems can and

do crop up once they hit the market. O course, some

newer prescription drugs are indeed more eective

and saer. Talk with your doctor about newer vs. older

medicines, including generic drugs.

3.Cnsiderenericdrus.Prescription medicines go generic when acompanys patents on them have lapsed, usually ater

about 12 to 15 years. At that point, other companies

can make and sell the drugs. enerics are much less

epensive than newer brand-name medicines, but theyare not lesser quality drugs. Indeed, most generics

remain useul medicines even many years ater rst

being marketed. That is why more than 75 percent o all

prescriptions in the U.S. today are written or generics.

4.Keeu-t-daterecrds.Another important issue to talk with yourdoctor about is keeping a record o the drugs you take.

There are several reasons or this:

first, i you see several doctors, each may not be

aware o medicines the others have prescribed.

Second, since people dier in their response to

medications, its common or doctors today to

prescribe several medicines beore nding one that

works well or best.

Third, many people take several prescription

medications, nonprescription drugs, and dietary

supplements at the same time. They can interact

in ways that can either reduce the benet you get

rom the drug or be dangerous.

fourth, the names o prescription drugsboth

generic and brandare oten hard to pronounce

and remember.

for all these reasons, its important to keep a written

list o all the drugs and supplements you take and

periodically review it with your doctors.

5.Knwtheacts.finally, always be sure that you understandthe dose o the medicine being prescribed and howmany pills you are epected to take each day. Your

doctor should tell you this inormation. When you

ll a prescription at a pharmacy, or i you get it by

mail, check to see that the dose and the number o

pills per day on the bottle match the amounts your

doctor told you.

5 istalkinWithyurctr


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15

Our evaluation is based primarily on an independentscientic review o the studies and research literature

on PPIs. A team o physicians and researchers at the

Oregon Health & Science University vidence-Based

Practice Center conducted the analysis as part o the

Drug ectiveness Review Project, or DRP. DRP is

a rst-o-its-kind multi-state initiative to evaluate the

comparative eectiveness and saety o hundreds o

prescription drugs.

A synopsis o DRPs analysis o the PPIs is the basis

or this report. A consultant to Consumer ReportsBest Buy Drugs is also a member o the Oregon-based

research team, which has no nancial interest in any

pharmaceutical company or product. The ull DRP

review o PPIs is available at http://derp.ohsu.edu/

about/nal-document-display.cm. (This is a long and

technical document written or physicians.)

To supplement the DRP analysis, a member o DRP

also conducted an updated search or relevant studies

that have been published since the publication o the

DRP report.

cept where noted, the prices in this report or PPIs

are national averages based on sales o prescription

drugs in retail outlets. They reect the retail price

paid or a months supply o each drug in April 2013

and were obtained rom a healthcare inormation

company that tracks the sales o prescription drugs

in the U.S. for Prilosec OTC, Prevacid 24HR, and

their generic counterparts, prices were obtained by

Consumer Reports secret shoppers at ve major chain

pharmacies (CVS, Rite Aid, Target, Walgreens, andWalmart) and local supermarkets across the U.S. in

January 2013. The average price or Zegerid OTC is

based on prices at ve online pharmacy stores (CVS,

Rite Aid, Target, Walgreens, and Walmart) in ay 2013.

Consumer Reports Best Buy Drugs selected theBest Buy Drugs using the ollowing criteria. The drug

(and dose) had to:

Be in the top tier o eectiveness among the PPIs.

Have a saety record similar to or better than

other PPIs.

Have an average monthly cost lower than other

PPIs meeting the rst two criteria.

The Consumers Reports Best Buy Drugs methodology

is described in more detail in the methods section at

www.CRBestBuyDrugs.org.

HwWepickedthe

BestBuypps
http://derp.ohsu.edu/about/final-document-display.cfmhttp://derp.ohsu.edu/about/final-document-display.cfmhttp://derp.ohsu.edu/about/final-document-display.cfmhttp://derp.ohsu.edu/about/final-document-display.cfmhttp://derp.ohsu.edu/about/final-document-display.cfm


16/18


16

This copyrighted report can be downloaded

ree, reprinted, and disseminated or individual

noncommercial use without permission romConsumers Union or Consumer Reports magazine

as long as it is clearly attributed to Consumer

Reports Best Buy Drugs. We encourage its wide

dissemination as well or the purpose o inorming

consumers. But Consumers Union does not authorize

the use o its name or materials or commercial,

marketing, or promotional purposes. Any organization

interested in broader distribution o this report should

email [email protected]. Consumer Reports BestBuy Drugs is a trademarked property o Consumers

Union. All quotes rom the material should cite

Consumer Reports Best Buy Drugs as the source.

2013 Consumers Union o U.S., Inc.

Consumer Reports is an independent and nonprot

organization whose mission since 1936 has been to

provide consumers with unbiased inormation ongoods and services and to create a air marketplace.

Its website is www.ConsumerReports.org.

Consumer Reports Best Buy Drugs is a public-

education project administered by Consumers Union.

These materials were made possible by the state

Attorney eneral Consumer and Prescriber ducation

rant Program, which is unded by a multistate

settlement o consumer-raud claims regarding the

marketing o the prescription drug Neurontin.

The ngelberg foundation provided a major grant to

und the creation o the project rom 2004 to 2007.

Additional initial unding came rom the National

ibrary o edicine, part o the National Institutes o

Health. A more detailed eplanation o the project is

available at www.CRBestBuyDrugs.org.

We ollowed a rigorous editorial process to ensure that

the inormation in this report and on the Consumer

Reports Best Buy Drugs website is accurate anddescribes generally accepted clinical practices. I we

nd an error or are alerted to one, we will correct it

as quickly as possible. But Consumer Reports and its

authors, editors, publishers, licensers, and suppliers

cannot be responsible or medical errors or omissions,

or any consequences rom the use o the inormation

on this site. Please reer to our user agreement at

www.CRBestBuyDrugs.org or urther inormation.

Consumer Reports Best Buy Drugs should not be

viewed as a substitute or a consultation with amedical or health proessional. This report and the

inormation on www.CRBestBuyDrugs.org are provided

to enhance your communication with your doctor

rather than to replace it.

SharinthisRert

Abuts


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17

1. Adachi, K., et al., Symptom relie in patients with reuesophagitis: comparative study o omeprazole, lansoprazole,and rabeprazole. Journal o astroenterology & Hepatology.

2003;18 (12):1392-8.2. Armstrong, D., et al., The role o acid suppression in patients

with endoscopy-negative reu disease: the eect o treatmentwith esomeprazole or omeprazole. Alimentary Pharmacology &Therapeutics. 2004;20(4):413-21.

3. Bardhan K.D., Achim A., Riddermann T., Paenberger B.A clinical trial comparing pantoprazole and esomeprazoleto eplore the concept o achieving complete remission ingastro esophagealreu disease.Alimentary Pharmacology &Therapeutics . June 15 2007;25(12):1461-1469.

4. Bytzer P., orocutti A., Kennerly P., Ravic ., iller N.,Investigators RT. ect o rabeprazole and omeprazole on theonset o gastroesophageal reu disease symptom relie duringthe rst seven days o treatment. Scandinavian Journal o

Gastroenterology. Oct 2006;41(10):1132-1140.5. Caro, J.J., et al., Healing and relapse rates in gastroesophageal

reu disease treated with the newer proton-pump inhibitorslansoprazole, rabeprazole, and pantoprazole compared withomeprazole, ranitidine, and placebo: evidence rom randomizedclinical trials. Clin Ther 2001 July; 23:998-1017.

6. Castell, D.O., et al., cacy and saety o lansoprazole in thetreatment o erosive reu esophagitis. American Journal oastroenterology 1996;91(9):1749-1757.

7. Castell, D.O., et al., someprazole (40 mg) compared withlansoprazole (30 mg) in the treatment o erosive esophagitis.American Journal o astroenterology 2002;97(3):575-83.

8. Corinaldesi, R., et al., Pantoprazole and omeprazole in thetreatment o oesophagitis: a uropean multicenter study.

AlimentaryPharmacology & Therapeutics 1995;9:667-71.

9. Dekkers, C.P., et al., Comparison o rabeprazole 20 mg vs.omeprazole 20 mg in the treatment o active duodenal ulcer:a uropean multicentre study. Alimentary Pharmacology &Therapeutics 1999;13(2):179-86.

10. Delchier, J.C., et al., 20 mg once daily or 10 mg twice daily isequivalent to omeprazole 20 mg once daily in the healing oerosive gastroesophageal reu disease. Scandinavian Journalo astroenterology 2000;35:1245-50.

11. Devault K.R., Johanson J.f., Johnson D.A., iu S, Sostek .B.aintenance o healed erosive esophagitis: a randomized si-month comparison o esomeprazole twenty milligrams withlansoprazole teen milligrams. Clinical Gastroenterology &Hepatology. Jul 2006;4(7):852-859.

12. Dial, S., et al., Use o gastric acid-suppressive agents and therisk o community acquired Clostridium dicile-associateddisease. JAA. 2005; 294:2989-2995.

13. Dupas, J.., Houcke, P., Samoyeau, R., french CollaborativePantaprazole Study . Pantoprazole vs. lansoprazole in frenchpatients with reu esophagitis. astroenterologie Clinique et

Biologique 2001;25(3):245-50.14. illessen, A., et al., 40mg pantoprazole and 40mg

esomeprazole are equivalent in the healing o esophageallesions and relie rom gastroesophageal reu disease-related symptoms. Journal o Clinical astroenterology.2004;38(4):332-40.

15. latzel D., Abdel-Qader ., atz ., Paenberger B.Pantoprazole 40 mg is as eective as esomeprazole 40 mg torelieve symptoms o gastroesophageal reu disease ater 4weeks o treatment and superior regarding the prevention osymptomatic relapse. Digestion. 2006;74(3-4):145-154.

16. oh K-. Benamouzig R. Sander P. Schwan T. cacy opantoprazole 20 mg daily compared with esomeprazole 20mg daily in the maintenance o healed gastroesophageal reu

disease: a randomized, double-blind comparative trial - theANCIPAT study. uropean Journal o astroenterology &Hepatology. arch 2007;19(3):205-211.

17. Hatlebakk, J.., et al., ansoprazole vs. omeprazole in short-term treatment o reu oesophagitis. Results o a Scandinavianmulticentre trial. Scandinavian Journal o astroenterology1993;28(3):224-8.

18. Hellstrom, P.., et al., The choice o proton pump inhibitor: doesit matter? Pharmacology & Toicology, 2004;94 (3):106-11.

19. Holtmann, ., et al., A randomized, double-blind, comparativestudy o standard-dose rabeprazole and high-dose omeprazolein gastroesophageal reu disease. Alimentary Pharmacology& Therapeutics. 2002;16(3):479-85.

20. Howden, C.W. et al., vidence or therapeutic equivalence

o lansoprazole 30mg and esomeprazole 40mg in thetreatment o erosive oesophagitis. Clinical Drug Investigation2002;22(2):99-109.

21. Ji S., Kim H.S., Kim J.W. et al. Comparison o the ecacy orabeprazole 10 mg and omeprazole 20 mg or the healingrapidity o peptic ulcer diseases.Journal o Gastroenterology &Hepatology. Sept. 2006;21(9):1381-1387.

22. Kahrilas, P.J. et al., someprazole improves healing andsymptom resolution as compared with omeprazole in reuoesophagitis patients: a randomized controlled trial. Thesomeprazole Study Investigators. Alimentary Pharmacology &Therapeutics 2000;14(10):1249-58.

23. Klok, R.. et al., eta-analysis: comparing the ecacyo proton pump inhibitors in short-term use. AlimentaryPharmacology & Therapeutics, 2003;17(10):1237-45.

24. Korner, T. et al., Comparable ecacy o pantoprazoleand omeprazole in patients with moderate to severe reuesophagitis. Digestion 2003;67(1-2):6-13.

Reerences


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25. eontiadis, .I. et al., Proton pump inhibitor treatment orpeptic ulcer bleeding. The Cochrane Database o SystematicReviews 2006, Issue 1. (Jan. 25, 2006), www.thecochranelibrary.

com.26. cDonagh, .S. et al., Drug class review Proton Pump

Inhibitors. final Report Update 5. ay 2009. The Drugectiveness Review Project. www.ohsu.edu/drugeectiveness/reports/nal.cm.

27. ee, A.S. et al., Rapid symptom relie in reu esophagitis:a comparison o lansoprazole and omeprazole. AlimentaryPharmacology & Therapeutics 1996;10(5):757-63.

28. etz, D. C., Howden, C. W., Perez, . C., arsen, ., Oneil,J. and Atkinson, S. N. (2009), Clinical trial: delansoprazoleR, a proton pump inhibitor with dual delayed-releasetechnology, eectively controls symptoms and prevents relapsein patients with healed erosive oesophagitis. AlimentaryPharmacology & Therapeutics, 29: 742754. doi: 10.1111/j.1365-

2036.2009.03954..29. ulder, C.J. et al., ansoprazole 30mg vs. omeprazole 40mg

in the treatment o reu esophagitis grade II, III and IV,Dutch Study roup. uropean Journal o astroenterology &Hepatology 1996;8(11):1101-6.

30. ulder, C.J. et al., A double-blind, randomized comparisono omeprazole ultiple Unit Pellet System (UPS) 20mg,lansoprazole 30mg and pantoprazole 40mg in symptomaticreu oesophagitis ollowed by 3 months o omeprazole UPSmaintenance treatment: a Dutch multicentre trial. uropeanJournal o astroenterology & Hepatology 2002;14(6):649-56.

31. Regula J., Butruk ., Dekkers C.P. et al. Prevention o NSAID-associated gastrointestinal lesions: a comparison studyzgastroenterology. 2006;101(8):1747-1755.

32. Richter, J.. et al, cacy and saety o esomeprazolecompared with omeprazole in RD patients with erosiveesophagitis: a randomized controlled trial. American Journal oastroenterology 2001;96(3):656-65.

33. Richter, J.. et al., Comparing lansoprazole and omeprazolein onset o heartburn relie: results o a randomized, controlledtrial in erosive esophagitis patients. American Journal oastroenterology 2001;96(11):3089-98.

34. Schmitt C., ightdale C.J., Hwang C., Hamelin B. A multicenter,randomized, double-blind, 8-week comparative trial o standarddoses o esomeprazole (40 mg) and omeprazole (20 mg) orthe treatment o erosive esophagitis. Digestive Diseases &Sciences. ay 2006;51(5):844-850.

35. Shaheen, N. and Ransoho, D.f., astroesophageal reu,Barretts esophagus, and esophageal cancer: scientic review.JAA. 2002 (April 17); 287(15):1972-81.

36. Sharma, P., Shaheen, N. J., Perez, . C., Pilmer, B. ., ee, .,Atkinson, S. N. and Peura, D. (2009), Clinical trials: healingo erosive oesophagitis with delansoprazole R, a proton

pump inhibitor with a novel dual delayed-release ormulation results rom two randomized controlled studies. AlimentaryPharmacology & Therapeutics, 29: 731741. doi: 10.1111/j.1365-2036.2009.03933..

37. Thjodleisson, B. et al., Rabeprazole vs. omeprazole inpreventing relapse o erosive or ulcerative gastroesophagealreu disease: a double-blind, multicenter, uropean trial.The uropean Rabeprazole Study roup. Digestive Diseases &Sciences. 2000;45 (5):845-53.

38. Van Pinteren, B. et al., Short-term treatment with protonpump inhibitors, H2-receptor antagonists and prokinetics orgastroesophageal reu disease-like symptoms and endoscopynegative reu disease. Cochrane Database o SystematicReviews. (4):CD002095, 2001.

39. Vcev A., Begic I., Ostojic R. et al. someprazole vs. pantoprazoleor healing erosive oesophagitis. Collegium Antropologicum.Sept. 2006;30(3):519-522.

Reerences
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ppisupdate-final.pdf

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