Why are ppis enteric coated

Thus, expected therapeutic effects must always be balanced with possible adverse events Fig. The majority of adverse effects related to PPI administration are reported to occur after long-term administration has been given. For symptom control in patients with low grade reflux esophagitis, intermittent or on-demand administration may be effective enough.

Low grade reflux esophagitis, such as Los Angeles grade A or B, has repeatedly been reported not to progress to high grade reflux esophagitis or develop clinically relevant complications, including bleeding and esophageal stricture, even without intensive treatment. Therefore, long-term PPI administration may be necessary for maintenance treatment mainly in patients with high grade reflux esophagitis, Los Angeles grade C or D.

Therefore, for risky cases, PPI administration for prevention of recurrence is considered to be a reasonable option. However, for patients without such risks, long-term PPI use should be avoided. Majority of reported adverse effects of PPIs are conflicting and their clinical impacts are not large enough.

Since most of the studies concerning the adverse events of PPIs are retrospective and observational, the inclusion risks of potential bias are not negligible. In these conditions, only the study results showing the large clinical impact can be reliable and clinically important. Therefore, the presence of clinically meaningful risk of long-term PPIs administration is considered to be not fully established. However, even under these conditions, specialists in gastroenterology must always be careful to balance the merits and demerits of long-term PPI administration in daily medical practice.

In conclusion, known risks of long-term PPI administration must be considered in clinical practice, though the majority of evidence presented in regard to such risks is not consistent or adequate to make firm conclusions. Author contributions: Yoshikazu Kinoshita wrote this article; and Norihisa Ishimura and Shunji Ishihara gave important information and advices for the construction of this article. All of them read the final version of the article and agreed the contents of the article.

Title Author Keyword Volume Vol. Archives Top 10 DOIs. All rights reserved. Possible Allergic Reaction to Drug Chemicals Anaphylaxis, pancytopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, acute liver damage, Lyell syndrome, Stevens-Johnson syndrome, interstitial nephritis, and rhabdomyolysis may occur in a small number of cases treated with a PPI, as well many other types of drugs. Acute Interstitial Nephritis and Chronic Kidney Disease It has been reported that interstitial nephritis may occur in patients treated with a PPI, possibly because of an allergic reaction to the drug, though the precise mechanism is not clear.

Dementia Recently, a group of investigators reported 2 publications and suggested the increased risk of dementia in elderly persons treated with PPIs based on retrospective studies on a German database. Pneumonia Administration of PPIs decreases the bactericidal effect of gastric juice by increasing intra-gastric and lower esophageal intra-luminal pH. Gastric Neuroendocrine Tumor PPI administration increases plasma gastrin concentration by increasing intra-gastric pH.

Gastric Fundic Mucosal Hypertrophy Hypergastrinemia increases proliferation of gastric mucosal stem cells located in the neck area of gastric fundic glands in addition to gastric ECL cells. Changes in Gut Microbiome and Small Intestinal Bacterial Overgrowth PPIs have been reported to change the gut microbiome and increase the number of Streptococcus organisms, which densely colonize the oral cavity.

Hypomagnesemia Magnesium, important for regulation of neuromuscular and various enzyme activities, is absorbed from the small intestine and excreted in urine. Decreased Absorption of Other Nutrients Some nutrients require gastric acid for effective absorption, including iron, calcium, and vitamin B Gastric Cancers In patients infected with H. Colon Cancers Some colon cancer cells have been reported to have gastrin receptors, which were found to be linked to cell proliferation.

Spontaneous Bacterial Peritonitis and Hepatic Encephalopathy Spontaneous bacterial peritonitis is a bacterial infection of the abdominal cavity observed in cases with ascites caused by liver cirrhosis. Drug Interactions in the Gastrointestinal Tract Absorption of several different drugs is under the strong influence of gastric acid secretion, such as digitalis, which is degraded by gastric acid in the stomach.

Acid-inhibition unrelated adverse events reported during proton pump inhibitor administration. Possible evidence level and effect size of each adverse effect is shown.

Acid-inhibition related adverse events reported during proton pump inhibitor administration. Beneficial effects and possible adverse effects need to be balanced, when proton pump inhibitors PPIs are administered as many other drugs.

PPIs also have several acid-inhibition related and unrelated adverse effects although the clinical impacts of these adverse events are not so serious. However, balancing beneficial and adverse effects as well as selecting appropriate patients who will get larger benefits by the PPIs administration are critically important.

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World J Nephrol ; PPIs only suppress H. A combination of adequate acid suppression and antibiotic therapy is necessary for the successful eradication of H.

NSAIDs cause peptic ulcers by inhibiting prostaglandin synthesis and weakening gastroduodenal mucosal defenses. PPIs are the treatment of choice for large or complicated ulcers, 2 , 16 and they may also be used for prevention of NSAID—induced ulcers.

Omeprazole at a dosage of 20 mg daily has been shown to be better tolerated and associated with a lower relapse rate than misoprostol Cytotec at a dosage of mcg twice daily. PPIs are inactivated by exposure to gastric juice and are delivered in delayed-release gelatin capsules containing enteric-coated granules omeprazole and lansoprazole or in delayed-release enteric-coated tablets rabeprazole and pantoprazole. Both of these agents should be taken 30 minutes before meals, and their capsules should not be opened, chewed, or crushed, but should be swallowed whole.

Other methods of administering omeprazole, lansoprazole, 2 , 8 , 9 or esomeprazole 12 have been recommended for patients who are unable to swallow intact capsules. The capsules may be opened and the granules sprinkled over a tablespoon of applesauce, pudding, yogurt, or cottage cheese; the food must be swallowed immediately without stirring, crushing, or chewing.

In patients with nasogastric or gastrostomy tubes, the granules in one capsule may be mixed with 40 mL of apple juice and injected through the tube, which should be flushed with additional juice to clear the tube. Rabeprazole is supplied in one dose of 20 mg, and pantoprazole Protonix is supplied in one dose of 40 mg.

Both agents must be swallowed whole without crushing, chewing, or splitting. Rabeprazole should be taken after meals, but pantoprazole may be taken without regard to meals. Antacids may be administered concomitantly with all PPIs. Dosage adjustments for PPIs are not necessary in elderly patients or those with renal failure or mild hepatic impairment. Lansoprazole, rabeprazole, and pantoprazole should be used with caution in patients with severe hepatic impairment.

The FDA has not approved pantoprazole for maintenance therapy because safety has not been established beyond 16 weeks. At this time, pantoprazole is indicated by the FDA only for the treatment of erosive esophagitis in a dosage of 40 mg daily for eight to 16 weeks. The intravenous dosage is the same as the oral dosage 40 mg and should be administered slowly over two to 15 minutes. Esomeprazole is the s-isomer of omeprazole. It is more bioavailable than omeprazole as the result of a lesser first-pass effect and slower plasma clearance.

Esomeprazole in dosages of 20 and 40 mg produces higher hour intragastric pH levels than omeprazole, thus possibly resulting in superior acid control.

The incidence and types of adverse effects appear to be similar to those of omeprazole. Esomeprazole is supplied as delayed-release capsules containing enteric-coated pellets and is available in doses of 20 and 40 mg.

It should be taken one hour before meals, and dosage adjustment is not necessary in elderly patients or those with mild to moderate hepatic impairment. Daily dosages should not exceed 20 mg in patients with severe hepatic impairment. Esomeprazole is indicated for the short-term four to eight weeks treatment and healing of erosive esophagitis. If needed, an additional four to eight weeks of therapy may be considered.

It is also indicated for maintenance therapy of erosive esophagitis; however, studies do not extend beyond six months of use.

Esomeprazole, used as part of triple therapy, is indicated for the eradication of H. Up to 4 weeks; most will heal in this period; some patients may require additional therapy. Helicobacter pylori eradication for reduction of duodenal ulcer recurrence. Triple therapy: omeprazole, 20 mg, clarithromycin, mg, and amoxicillin, 1, mg, each taken twice daily. Triple therapy: 10 days, plus 18 days of omeprazole therapy if an ulcer is present at initiation of treatment.

Triple therapy: lansoprazole, 30 mg, amoxicillin, 1, mg, and clarithromycin, mg, each taken twice daily. Dual therapy: omeprazole, 40 mg daily, and clarithromycin, mg, each three times daily. Dual therapy: 14 days, plus 14 days of omeprazole therapy at 20 mg daily if an ulcer is present at initiation of treatment. Dual therapy: lansoprazole 30 mg, and amoxicillin, 1, mg, each taken three times daily. Maintenance therapy for healed duodenal ulcer. Dosages vary; recommended starting dosage is 60 mg daily; dosages of mg three times daily may be needed; dosages of more than 80 mg daily should be divided.

Dosages vary; usual starting dosage is 60 mg daily, up to 90 mg twice daily; dosages of more than mg daily should be divided.

Dosages vary; usual starting dosage is 60 mg daily, and dosages of 60 mg twice daily may be required. Information from references 2 , 6 , and 8 through Therefore, PPIs may be more cost-effective than H 2 blockers, especially in patients with more severe acid-peptic disorders, because of their lower and less frequent dosing requirements and their comparatively shorter duration of required therapy.

All five PPIs appear to have similar efficacy in the treatment of various acid-peptic disorders. The newer agents, rabeprazole and pantoprazole, seem to have fewer drug interactions.

This is a particularly important consideration in older patients who are already taking several other medications. While the average wholesale prices of all agents in this class are similar, pantoprazole is the least expensive. Some controversy remains regarding the need to endoscopically evaluate patients before prescribing PPIs. It would be prudent to consider endoscopic evaluation before initiating PPI therapy in patients 45 years or older and in those with atypical symptoms because pre-endoscopy treatment with a PPI could mask gastric cancer.

While some authorities recommend that the H. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. He received his medical degree from the University of Pennsylvania School of Medicine, Philadelphia, and completed a residency in family practice at York Pa.

Address correspondence to Rundsarah M. Tahboub, M. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest.

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