What Proton Pump Inhibitor (PPI) to start in patients on steroid therapy?

Proton Pump Inhibitor Selection for Patients on Steroid Therapy

Pantoprazole is the recommended PPI for patients on steroid therapy due to its lower risk of drug interactions and favorable safety profile. 1, 2

Rationale for PPI Use with Steroids

• PPIs are recommended for patients on steroid therapy to prevent gastrointestinal complications, particularly when using moderate to high doses of corticosteroids 3
• The British Society of Gastroenterology strongly recommends using a histamine 2 antagonist or PPI during steroid therapy 3
• For patients at increased risk of gastrointestinal bleeding (including those on steroids), PPI therapy is considered reasonable 3

PPI Selection Considerations

First-Line Choice: Pantoprazole

• Pantoprazole has a lower propensity for drug interactions compared to other PPIs due to minimal inhibition of CYP450 enzymes 1, 2
• It has a relatively long duration of action compared to other PPIs, providing consistent acid suppression 1
• To date, no clinically significant drug-drug interactions have been identified with pantoprazole in numerous interaction studies 1
• Pantoprazole has lower risk of interactions with medications that may be co-administered with steroids 2

Alternative Options

• Omeprazole is the most extensively studied PPI but has the highest risk for drug interactions among PPIs 2
• Rabeprazole also has a low risk for drug interactions similar to pantoprazole 2
• Lansoprazole and esomeprazole are effective alternatives but have intermediate risk of drug interactions 2

Dosing Recommendations

• Standard dosing of pantoprazole 40 mg once daily is appropriate for most patients on steroid therapy 1
• For patients with severe acid-related disorders or at very high risk of GI complications, pantoprazole 40 mg twice daily may be considered 3
• Duration of PPI therapy should match the duration of steroid treatment 3

Special Considerations

• Patients with additional risk factors for GI bleeding should definitely receive PPI prophylaxis while on steroids, including those with: 3, 4

  • History of peptic ulcer disease
  • Concurrent NSAID use
  • Advanced age
  • Concomitant anticoagulant therapy
  • Higher doses of steroids (>40 mg prednisone or equivalent)
  • Multiple comorbidities
  • Recent hospitalization

• For patients on immunosuppressive doses of steroids (≥20 mg/day of prednisone or equivalent for >2 weeks), PPI prophylaxis is particularly important 5

Common Pitfalls to Avoid

• Avoid omeprazole in patients taking multiple medications due to higher risk of drug interactions 2
• Do not discontinue PPI therapy prematurely before steroid therapy is completed 3
• Recognize that PPI therapy is often underutilized in steroid users - only 7.6% of patients starting corticosteroids receive appropriate PPI prophylaxis 4
• Be aware that patients on high-dose steroids (>40 mg/day prednisone) have nearly twice the odds of needing PPI therapy but are often not prescribed it prophylactically 4

By selecting pantoprazole as the PPI of choice for patients on steroid therapy, you can provide effective gastric protection while minimizing the risk of drug interactions and adverse effects.