Omeprazole Dosing Recommendations
For GERD and peptic ulcer disease, omeprazole 20 mg once daily taken 30-60 minutes before meals is the standard initial dose, with treatment duration of 4-8 weeks for most indications. 1, 2
Standard Dosing by Indication
Active Duodenal Ulcer
- 20 mg once daily for 4 weeks 2
- Most patients heal within 4 weeks; an additional 4 weeks may be given if needed 2
Active Gastric Ulcer
- 40 mg once daily for 4-8 weeks 2
Symptomatic GERD
Erosive Esophagitis (EE)
- 20 mg once daily for 4-8 weeks 2
- If no response after 8 weeks, an additional 4 weeks may be considered 2
- Patients with severe erosive esophagitis (LA Classification grade C/D) require continuous daily maintenance therapy 1
Maintenance of Healing of EE
- 20 mg once daily 2
- Controlled studies do not extend beyond 12 months 2
- After initial symptom control, step down to the lowest effective dose 1
Helicobacter pylori Eradication
- Triple therapy: Omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days 2
- If ulcer present at initiation, continue omeprazole 20 mg once daily for additional 18 days 2
- Dual therapy: Omeprazole 40 mg once daily + clarithromycin 500 mg three times daily for 14 days 2
Pathological Hypersecretory Conditions (Zollinger-Ellison Syndrome)
- Starting dose: 60 mg once daily, adjusted to patient needs 2
- Daily dosages greater than 80 mg should be divided 2
- Dosages up to 120 mg three times daily have been administered 2
Pediatric Dosing (Ages 2-16 Years)
Weight-Based Dosing
- 10 to <20 kg: 10 mg once daily 2
- ≥20 kg: 20 mg once daily 2
- Treatment duration: 4 weeks for symptomatic GERD, 4-8 weeks for erosive esophagitis 2
Important Administration Guidelines
Timing and Method
- Take before meals, not at bedtime 1
- Swallow capsules whole; do not chew 2
- For patients unable to swallow: Open capsule, mix pellets with 1 tablespoon applesauce, swallow immediately without chewing pellets 2
- Antacids may be used concomitantly 2
Dose Escalation Considerations
When Standard Dosing Fails
- If symptoms persist after 4-8 weeks of once-daily therapy, twice-daily dosing may be considered, though this is not FDA-approved 1
- For extraesophageal GERD syndromes with typical GERD symptoms, twice-daily dosing for 2-3 months may be considered as empiric therapy 1
- Most patients on twice-daily dosing should be stepped down to once-daily dosing 1
Evidence Limitations
- Double-dose PPIs have not been studied in randomized controlled trials and are not FDA-approved 1
- Up to 15% of PPI users are on higher-than-standard doses without clear evidence of benefit 1
Long-Term Management
Maintenance Therapy
- Patients with Barrett's esophagus, severe erosive esophagitis, or esophageal strictures require long-term PPI use 1
- All patients on long-term therapy should have their need for continued treatment periodically reassessed 1
- The indication for PPI therapy should be clearly documented 1
Step-Down Strategy
- After initial symptom control, consider step-down to the lowest effective dose 1
- Patients without definitive indication for chronic PPI use should be considered for trial of de-prescribing 1
- Most patients with GERD have non-erosive disease and may not require continuous long-term therapy 1
Common Pitfalls and Caveats
Dosing Errors
- Taking PPIs at bedtime instead of before meals reduces efficacy 1
- Twice-daily dosing is commonly prescribed but lacks strong evidence support 1
- Dose reduction below recommended levels should be avoided 3
Inappropriate Use
- Overuse in infants with reflux is concerning; placebo-controlled trials have not demonstrated superiority over placebo for reducing irritability 4
- Clear communication about the indication for PPI therapy is essential 3
Special Populations
- Dosage reduction to 10 mg once daily is recommended for patients with hepatic impairment and Asian patients when used for maintenance of healing of EE 2