According to the 2022 American College of Gastroenterology (ACG) guidelines for the management of gastroesophageal reflux disease (GERD), patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms should initiate an 8-week trial of empiric proton pump inhibitors (PPIs) once daily. Treatment with PPIs is recommended over treatment with histamine-2-receptor antagonists (H2RAs) to heal and maintain healing erosive esophagitis. Additionally, maintenance PPI therapy indefinitely is recommended for patients with Los Angeles grace C or D esophagitis. On-demand or intermittent PPI therapy should be used for heartburn symptom control in patients with non-erosive reflux disease (NERD). [1]
Meta-analyses suggest there is little difference overall for GERD symptom relief and healing rates between the 7 available PPIs; therefore, recommendations to use a specific PPI are not provided. However, data show wide variations in the acid-suppression potency of the different PPI preparations. If relative acid-suppression potencies of individual PPIs are standardized to omeprazole to yield “omeprazole equivalents” (OEs, with omeprazole having an OE of 1), the relative potencies of standard-dose pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole have been estimated at 0.23, 0.9, 1, 1.6, and 1.82 OEs, respectively. The varying acid-suppression potency may result in wide variation in individual intragastric pH control between PPIs. Guidance for choosing a specific PPI for elderly patients is not provided. [1], [2], [3]
A review of proton pump inhibitor use in the elderly population for treatment of acid-related disease, including gastro-oesophageal reflux disease (GORD), discusses that rabeprazole may be particularly suited for use in older patients since it requires no dosing adjustment in the elderly or patients with renal insufficiency or mild-to-moderate hepatic disease. Additionally, it is relatively free of clinically significant drug-drug interactions, unlike omeprazole. The author also suggests that the clinical and pharmacokinetic profiles for rabeprazole make it an appropriate first choice for managing older patients with GORD. [4]
A 2016 network meta-analysis aimed to investigate the efficacy and safety of different PPIs in treating patients with NERD. A total of fifteen studies (N= 6,299) with an average of 394 patients per trial were included for analysis. The positive rate of helicobacter pylori tests ranged from 13.4% to 52.7%. Compared with placebo groups, all interventions (dexlansoprazole 30 mg, dexlansoprazole 60 mg, omeprazole 10 mg, omeprazole 20 mg, lansoprazole 15 mg, lansoprazole 30 mg, esomeprazole 20 mg, esomeprazole 40 mg, rabeprazole 10 mg, and rabeprazole 20 mg) except rabeprazole 5 mg significantly increased rate of symptomatic relief. Omeprazole 20 mg resulted in a higher rate of symptomatic relief compared to rabeprazole 5 mg (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.16 to 5.42, p= 0.019) or omeprazole 10 mg (OR 1.89, 95 CI 1.34 to 2.67, p= 0.0005). Additionally, dexlansoprazole 30 mg significantly improved the rate of symptomatic relief compared with rabeprazole 5 mg (OR 2.64, 95% CI 1.08 to 6.43, p= 0.03). [5]
No significant difference was found between intervention groups for rates of adverse events. Based on a cluster plot, dexlansoprazole 30 mg was found to have the highest rate of symptomatic relief. Omeprazole 20 mg had the lowest incidence rate of adverse events, while lansoprazole 30 mg was associated with the highest incidence. The cluster plot shows that omeprazole 20 mg may be the best option for NERD treatment due to the high rate of symptomatic relief and low incidence rate of adverse events. This analysis is limited by the high risk of bias of included studies, which prevents sensitivity analyses from being performed. Additionally, this meta-analysis did not specifically evaluate the use of PPIs in elderly populations; the average age of patients from included studies ranged from 41.7 to 52 years. [5]