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Clinical Question:
Is there any difference between proton pump inhibitors for the
treatment of gastroesophageal reflux disease?
Bottom Line:
There is no significant difference between equivalent doses of proton pump
inhibitors, including equivalent doses of esomeprazole (Nexium) and
omeprazole (Prilosec OTC). The decision to choose one over another should be
based first on cost and second on individual patient response.
Reference:
Klok RM, Postma MJ, Van Hout BA, Brouwers JR. Meta-analysis: comparing the
efficacy of proton pump inhibitors in short-term use. Aliment Pharmacol Ther
2003;17:1237-45.
Study Design:
Meta-analysis (randomized controlled trials)
Funding:
Unknown/not stated
Setting:
Various (meta-analysis)
Synopsis:
This meta-analysis identified all double-blinded randomized controlled
trials comparing one proton pump inhibitor with another for the treatment of
gastroesphageal reflux disease (GERD), using endoscopic healing as the
referece standard for treatment success. A total of 19 studies with more
than 9000 patients were identified, most lasting 4 weeks. The following
comparisons were studied: pantoprazole 40 mg vs omeprazole 20 mg;
pantoprazole 20 mg vs omeprazole 20 mg; lansoprazole 30 mg vs omeprazole 20
mg; lansoprazole 15 mg vs omeprazole 20 mg; lansoprazole 30 mg vs omeprazole
40 mg; lansoprazole 30 mg vs pantoprazole 40 mg; rabeprazole 20 mg vs
omeprazole 20 mg; and rabeprazole 10 mg vs omeprazole 20 mg. Only one
comparison found a statistically significant difference between groups in
the treatment of GERD: esomeprazole 40 mg vs omeprazole 20 mg (80% vs 67%
response rate; P = .04; number needed to treat = 7). However, a comparison
in 1306 patients of equivalent doses of 20 mg esomeprazole vs 20 mg
omeprazole found no difference in endoscopic healing. Furthermore, the
response rates for omeprazole 20 mg in the 2 studies comparing it with
esomeprazole 40 mg were 65% and 67% -- considerably lower than in other
comparisons looking at this dose, in which the success rate was between 70%
and 91%. This would make esomeprazole look more effective in comparison.
Thus, although this comparison has never been made directly, it seems very
likely that 40 mg omeprazole ($38 per month over the counter) would be
similar in effectiveness to 40 mg of esomeprazole ($124 per month).
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