Examples of Proton Pump Inhibitors
The commonly available proton pump inhibitors (PPIs) include omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, and dexlansoprazole. 1
Available PPI Medications
The following PPIs are FDA-approved and available for clinical use:
Omeprazole - Available as delayed-release capsules for oral use, approved for treatment of duodenal ulcers, gastric ulcers, GERD, erosive esophagitis, H. pylori eradication (in combination with antibiotics), and hypersecretory conditions like Zollinger-Ellison syndrome 2, 3
Lansoprazole - Available as delayed-release capsules, indicated for duodenal ulcers (4 weeks), gastric ulcers (up to 8 weeks), GERD, erosive esophagitis (up to 8 weeks), H. pylori eradication (10-14 days with antibiotics), NSAID-associated ulcers, and hypersecretory conditions 2
Pantoprazole - Available as delayed-release tablets and IV formulation, approved for erosive esophagitis (up to 8 weeks), maintenance of EE healing, and hypersecretory conditions including Zollinger-Ellison syndrome 4
Rabeprazole - FDA-approved for patients 12 years and older 5
Esomeprazole - The S-isomer of omeprazole, approved for patients 1 year and older 5
Dexlansoprazole - A newer formulation included in the PPI class 1
Comparative Potency
When comparing equivalent acid suppression to 20 mg omeprazole 1:
- Lansoprazole 30 mg = 27 mg omeprazole equivalent
- Pantoprazole 40 mg = 9 mg omeprazole equivalent (lower potency)
- Rabeprazole 20 mg = 36 mg omeprazole equivalent (higher potency)
- Esomeprazole 20 mg = 32 mg omeprazole equivalent (higher potency)
Key Clinical Distinctions
All PPIs are metabolized by the hepatic cytochrome P-450 system, predominantly CYP2C19, which creates important differences in drug interactions 1. Omeprazole and lansoprazole have greater potential for drug-drug interactions compared to pantoprazole and rabeprazole 6.
Important Drug Interaction Considerations
Avoid omeprazole and esomeprazole with clopidogrel - These PPIs inhibit CYP2C19 and significantly reduce clopidogrel's antiplatelet activity, even when dosed 12 hours apart 5, 1
Pantoprazole is preferred with clopidogrel - It has lower potential for CYP2C19 inhibition and is the recommended alternative when PPI gastroprotection is needed in patients on antiplatelet therapy 5, 1
Pediatric Approvals
PPIs have varying age restrictions for pediatric use 5:
- Omeprazole, lansoprazole, and esomeprazole: approved for ages 1 year and older
- Rabeprazole: approved for ages 12 years and older
- Pantoprazole: approved for ages 5 years and older for erosive esophagitis only
Mechanism of Action
PPIs are prodrugs that become activated in the acidic environment of gastric parietal cells, where they covalently bind to and irreversibly inhibit the H+/K+-ATPase proton pump 1, 6. This provides potent acid suppression lasting up to 36 hours, with 37-68% reduction in 24-hour acid production 1.