What is the strength of each Proton Pump Inhibitor (PPI)?

From the Guidelines

Proton Pump Inhibitors (PPIs) vary in potency, with esomeprazole and rabeprazole generally considered the most potent at standard doses, as evidenced by a study published in the Annual Review of Medicine in 2022 1. The potency of each PPI can be compared as follows:

• Esomeprazole 20mg is equivalent to 32mg of omeprazole
• Rabeprazole 20mg is equivalent to 36mg of omeprazole
• Lansoprazole 30mg is equivalent to 27mg of omeprazole
• Pantoprazole 40mg is equivalent to 9mg of omeprazole, and is generally considered to be less potent than esomeprazole and rabeprazole Some key points to consider when choosing a PPI include:
• The dose of PPI required to achieve optimal acid suppression, with a minimum dose of 40mg of omeprazole or equivalent b.i.d. recommended 1
• The potential for drug interactions, particularly with other medications that may affect the metabolism of the PPI
• The individual patient's response to the PPI, with some patients requiring twice-daily dosing or higher doses for conditions like severe GERD or Zollinger-Ellison syndrome It is also worth noting that while the potency of PPIs can vary, all PPIs work by the same mechanism - irreversibly inhibiting the hydrogen-potassium ATPase enzyme in gastric parietal cells, thereby reducing acid production. A study published in the Journal of Hepatology in 2020 provides a useful comparison of the dose equivalence among different PPIs, including omeprazole, lansoprazole, esomeprazole, pantoprazole, and rabeprazole 1. In general, esomeprazole and rabeprazole are considered to be the most potent PPIs, and are often recommended as first-line treatment for conditions like GERD and peptic ulcer disease, due to their high potency and efficacy in achieving optimal acid suppression 1.

From the Research

Strength of Each Proton Pump Inhibitor (PPI)

The strength of each PPI can be compared based on their ability to suppress gastric acid secretion and provide symptom relief in patients with reflux esophagitis. The following points summarize the strength of each PPI:

• Esomeprazole: Esomeprazole has been shown to be more effective than other PPIs in providing rapid relief of heartburn symptoms and acid reflux symptoms in patients with reflux esophagitis 2. It also maintains intragastric pH above 4.0 for a longer period compared to other PPIs 3.
• Omeprazole: Omeprazole is considered a standard PPI, and its effectiveness has been compared to other PPIs in several studies. While it is effective in suppressing gastric acid secretion, it may not be as potent as esomeprazole in providing rapid symptom relief 2, 3.
• Lansoprazole: Lansoprazole has been shown to be similar in effectiveness to omeprazole in healing reflux esophagitis, but it may not be as potent as esomeprazole in providing rapid symptom relief 2, 4.
• Pantoprazole: Pantoprazole has been shown to be less effective than esomeprazole in maintaining intragastric pH above 4.0, but it is still effective in suppressing gastric acid secretion 3.
• Rabeprazole: Rabeprazole has been shown to be similar in effectiveness to omeprazole in healing reflux esophagitis, but it may not be as potent as esomeprazole in providing rapid symptom relief 2, 4.

Comparison of PPIs Based on Relative Potency

A study compared the relative potency of different PPIs based on their ability to increase intragastric pH above 4.0 5. The results showed that:

• Omeprazole and lansoprazole (30 mg): These PPIs are functionally equivalent to 20 mg of esomeprazole.
• Rabeprazole: Rabeprazole is also functionally equivalent to 20 mg of esomeprazole.
• Pantoprazole: Pantoprazole is less potent than esomeprazole, but its exact relative potency is not well established.

Factors Affecting PPI Strength

The strength of each PPI can be affected by several factors, including:

• Hepatic metabolism: PPIs undergo significant hepatic metabolism, which can affect their potency and potential for drug interactions 6.
• Genetic polymorphisms: Genetic polymorphisms, such as those affecting the CYP2C19 enzyme, can affect the metabolism of PPIs and their potency 6.
• Dosing regimen: The dosing regimen of PPIs can affect their potency, with twice-daily dosing being more effective than once-daily dosing in increasing intragastric pH above 4.0 5.