What is the recommended dose of Proton Pump Inhibitor (PPI)?

From the Guidelines

For the management of EoE, the recommended dose of proton pump inhibitors (PPIs) is omeprazole 20 mg two times per day. This recommendation is based on the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults, published in 2022 1. The guidelines suggest that PPI therapy should be given two times per day for at least 8–12 weeks prior to assessment of histological response while on treatment. A meta-analysis in 2015 described a non-significant trend towards increased efficacy for two times per day dosing compared with a one time per day dose.

Some key points to consider when prescribing PPIs for EoE include:

• The majority of published studies include 8 weeks of treatment with PPI followed by assessment of response by means of repeat endoscopy and oesophageal biopsies.
• Agents and doses varied widely, though regimes typically included a minimum dose of omeprazole 40 mg daily or equivalent.
• A significant difference in clinicopathological response rates was reported in patients with EoE prescribed high-dose PPI, for example, omeprazole 20 mg two times per day have been reported as being higher (50.8%), than in those given standard or low-dose regimes (35.8%).
• Treatment of 8–10 weeks conferred a response rate of 50.4%. Longer treatment duration (>10–12 weeks) was associated with a greater rate of response (65.2%) though the effect was observed to diminish in patients treated longer than this (44.1% response rate).

It's worth noting that while other studies discuss the use of PPIs in the context of GERD, such as the AGA clinical practice update on the personalized approach to the evaluation and management of GERD 1, the specific context of EoE management is addressed in the BSG and BSPGHAN guidelines 1. Therefore, the recommendation for omeprazole 20 mg two times per day is based on the most relevant and recent evidence for EoE management.

From the FDA Drug Label

Dosage and Administration 2. 1 Recommended Adult Dosage by Indication IndicationRecommended DoseFrequency Duodenal Ulcers Short-Term Treatment Maintenance of Healed 15 mg 15 mg Once daily for 4 weeks Once daily Eradication of H ree times daily for 14 days Benign Gastric Ulcer Short-Term Treatment 30 mg Once daily for up to 8 weeks NSAID-Associated Gastric Ulcer Healing Risk Reduction 30 mg 15 mg Once daily for 8 weeks † Once daily for up to 12 weeks † Gastroesophageal Reflux Disease (GERD) Short-Term Treatment of Symptomatic GERD Short -Term Treatment of Erosive Esophagitis 15 mg 30 mg Once daily for up to 8 weeks Once daily for up to 8 weeks ‡ Maintenance of Healing of Erosive Esophagitis 15 mgOnce daily § Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome 60 mg Once daily ¶

The recommended dose of lansoprazole varies by indication:

• Duodenal Ulcers: 15 mg once daily
• Benign Gastric Ulcer: 30 mg once daily
• NSAID-Associated Gastric Ulcer: 30 mg once daily
• Gastroesophageal Reflux Disease (GERD): 15 mg to 30 mg once daily
• Pathological Hypersecretory Conditions: 60 mg once daily 2

From the Research

PPI Dose Information

• The optimal dose of proton pump inhibitors (PPIs) varies depending on the specific condition being treated and the individual patient's response to therapy 3, 4, 5, 6, 7.
• For the treatment of gastric and duodenal ulcers, studies have shown that lansoprazole 30 mg daily is effective in achieving symptom relief and healing 3, 4.
• In the treatment of gastroesophageal reflux disease (GERD), PPIs such as omeprazole 20 mg daily are commonly used as initial therapy, with the goal of using the lowest effective dose 6, 7.
• Some studies have suggested that higher doses of PPIs may be necessary for certain patients, such as those with more severe symptoms or complications 4, 5.
• However, the use of high-dose PPIs should be balanced against the potential risks of long-term therapy, including adverse effects and interactions with other medications 7.

Factors Influencing PPI Dose

• The presence of Helicobacter pylori infection may influence the choice of PPI dose, as eradication of the infection is an important goal in the treatment of peptic ulcer disease 4.
• Patient factors, such as age, weight, and comorbidities, may also influence the optimal PPI dose 6, 7.
• The specific PPI used may also affect the dose, as different agents have varying potencies and pharmacokinetic profiles 5.

Clinical Considerations

• PPIs should be used at the lowest effective dose to minimize the risk of adverse effects and optimize patient outcomes 6, 7.
• Regular monitoring and follow-up are necessary to assess the effectiveness of PPI therapy and adjust the dose as needed 7.
• Alternative treatment options, such as lifestyle modifications and surgery, should be considered for patients who do not respond to PPI therapy or have contraindications to its use 6, 7.