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  • 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

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    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

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    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

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    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

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    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

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    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.

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    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.

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    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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    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

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    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

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    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

    Omeprazole 20 mg delayed-release capsules Prilosec One per day $236

    Omeprazole 20 mg delayed-release capsules eneric One per day $58

    Omeprazole 40 mg delayed-release capsules Prilosec One per day $374

    Omeprazole 40 mg delayed-release capsules eneric One per day $134

    Chsinapp

    ourBestBuypicks

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    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
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    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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    CoSERREpoRSBESByRgS

    18

    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

    http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/http://www.ohsu.edu/drugeffectiveness/reports/final.cfmhttp://www.ohsu.edu/drugeffectiveness/reports/final.cfmhttp://www.ohsu.edu/drugeffectiveness/reports/final.cfmhttp://www.ohsu.edu/drugeffectiveness/reports/final.cfmhttp://www.ohsu.edu/drugeffectiveness/reports/final.cfmhttp://www.thecochranelibrary.com/