Background

Proton pump inhibitors (PPIs) are a class of very effective and generally safe medicines used to treat heartburn, gastroesophageal reflux disease (GERD), and gastric ulcers.But not everyone who experiences heartburn needs one.

To help you and your doctor choose the right PPI if you need one, Consumer Reports Best Buy Drugs has evaluated the drugs in this category based on their effectiveness, safety, and cost. This brief is a summary of a 18-page report you can access on the Internet at CRBestBuyDrugs.org.

Our independent evaluations are based on scientific reviews conducted by the Oregon Health and Science University-based Drug Effectiveness Review Project. Grants from the Engelberg Foundation and the National Library of Medicine help fund Consumer Reports Best Buy Drugs. These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

Do You Need a PPI?

Several of the PPIs have been widely advertised to consumers and heavily promoted to physicians, and this has led to an overuse of the drugs in the treatment of garden-variety heartburn. PPIs are among the highest-selling classes of drugs in the U.S., with $9.5 billion in sales last year, and one of them, Nexium, was the top-selling of all drugs, earning nearly $6 billion in 2012, according to IMS Health, which tracks drug sales and marketing.

If you suffer from occasional heartburn and have not been diagnosed with GERD, nonprescription antacids such as Maalox, Mylanta, Rolaids, and Tums, or acid-reducing drugs known as H2 blockers, such as cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac) will very likely provide relief. All of those products are available without a prescription as low-cost generics.

Talk with your doctor about the role that dietary and lifestyle changes can play in alleviating heartburn, too, such as eating smaller meals and not lying down for at least three hours after eating, losing weight if you need to, and avoiding alcohol. If, however, you experience heartburn twice a week or more for weeks or months on end, have frequent regurgitation of food into your throat or mouth (with or without heartburn), or if your heartburn is not relieved by the drugs mentioned above, you may have GERD and may need a PPI. GERD is a condition that makes you prone to acid reflux and, over time, can cause damage to your esophagus.

Our Recommendations

Occasional heartburn is not worrisome or dangerous, and can be largely relieved by taking over-the-counter antacids or H2 blockers. Even if you have a period of time—say a couple of weeks—in which you get heartburn fairly regularly, you may not need anything stronger than those drugs.

However, if you have heartburn at least twice a week for weeks or months on end, have frequent regurgitation of food into your throat or mouth (with or without heartburn), or if your heartburn is not relieved by antacids or H2 blockers, you may have GERD, which could be helped by taking a PPI.

The seven available PPI medicines are roughly equal in effectiveness and safety but differ in cost. Three—omeprazole (Prilosec, Prilosec OTC), lansoprazole (Prevacid, Prevacid 24HR), and omeprazole/sodium bicarbonate (Zegerid, Zegerid OTC)—are available as both prescription and nonprescription drugs.


Four—lansoprazole, omeprazole, omeprazole/sodium bicarbonate, and pantoprazole (Protonix)—are available as both brand-name drugs and generics that contain the same active ingredient but cost significantly less.


Taking the evidence for effectiveness, safety, cost, and other factors into account, if you need a PPI, we have chosen the following as Consumer Reports Best Buy Drugs:

  • Generic omeprazole OTC
  • Generic lansoprazole OTC

Both of these drugs are available without a prescription. You could save $200 a month or more by choosing one of these medicines over more expensive prescription PPIs. If you have health insurance, find out if your plan will help pay for generic omeprazole OTC or generic lansoprazole OTC. If not, talk with your doctor about taking the PPI with the lowest out-of-pocket cost for you. If you have esophagitis (inflammation of the esophagus), you might want to consider esomeprazole (Nexium), pantoprazole (Protonix and generic), or rabeprazole (AcipHex). Some research suggests those
drugs could provide better healing from esophagitis.


Safety note: Several studies have now linked PPIs to a higher risk of pneumonia and infection with a bacterium called Clostridium difficile, and other studies have found that long-term use of PPIs may be associated with an increased risk of fractures. Talk with your doctor about those risks, especially if you must take a PPI over a long period of time. People who are 65 and older and those with chronic medical conditions should be vaccinated against pneumonia and get a flu shot every year. And we emphasize this recommendation for people in those categories who are also taking a PPI.


In addition, anyone taking clopidogrel (Plavix and generic), a blood thinner used to prevent clots after heart attacks and stent placement, should be especially cautious with PPIs, particularly omeprazole and esomeprazole because they can reduce clopidogrel’s effectiveness, which could increase the risk of another heart attack. Our medical advisers recommend that people taking clopidogrel should not take PPIs unless other treatments have not been adequate.


This report was updated in July 2013.

Effectiveness

General Effectiveness of PPIs1

Generic Name and Dose per Day

Brand Name

Symptom Relief at 4 Weeks, Average Percent of Patients (Range)

Esophageal Healing at 8 Weeks, Average Percent of Patients (Range)

Relapse Prevention. Average Percentage of Patients

Dexlansoprazole 30 mg

Dexilant

NA2

NA2

75%

Dexlansoprazole 60 mg

Dexilant

NA2

86% (82%-89%)

83%

Esomeprazole 20 mg

Nexium

NA2

87% (84%-91%)

87%

Esomeprazole 40 mg

Nexium

73% (65%-82%)

90% (88%-92%)

93%

Lansoprazole 30 mg

Prevacid

70% (61%-80%)

86% (83%-90%)

91%

Omeprazole 20 mg

Prilosec

65% (54%-76%)

85% (81%-88%)

86%-92%

Pantoprazole 20 mg

Protonix

77% (70%-84%)

77% (65%-88%)

55%-86%

Pantoprazole 40 mg

Protonix

72% (62%-83%)

89% (86%-92%)

78%

Rabeprazole 20 mg

Aciphex

69% (52%-86%)

82% (76%-89%)

89%

1. Effectiveness data presented for PPI dosage strengths that have been studied to date. Data are from individual

studies included in DERP’s analysis of the PPIs. Ranges given reflect findings from multiple studies.

2. NA = Data not available.

Cost Comparison

Generic Name

Brand Name1

Frequency of Use2

Average Monthly Cost3

Dexlansoprazole 30 mg sustained-release tablets

Dexilant

One per day

$188

Dexlansoprazole 60 mg sustained-release tablets

Dexilant

One per day

$183

Esomeprazole 20 mg capsules

Nexium

One per day

$240

Esomeprazole 40 mg capsules

Nexium

One per day

$234

Lansoprazole 20 mg delayed-release tablets (nonprescription)

Prevacid 24HR

One per day

$244

Lansoprazole 20 mg delayed-release tablets (nonprescription)

Generic

One per day

$174

Lansoprazole 15 mg delayed-release capsules

Prevacid

One per day

$265

Lansoprazole 15 mg delayed-release capsules

Generic

One per day

$119

Lansoprazole 15 mg delayed-release dissolvable tablets

Prevacid

One per day

$285

Lansoprazole 15 mg delayed-release dissolvable tablets

Generic

One per day

$161

Lansoprazole 30 mg delayed-release capsules

Prevacid

One per day

$275

Lansoprazole 30 mg delayed-release capsules

Generic

One per day

$107

Lansoprazole 30 mg delayed-release dissolvable tablets

Prevacid

One per day

$265

Lansoprazole 30 mg delayed-release dissolvable tablets

Generic

One per day

$163

Omeprazole 20 mg tablets (nonprescription)

Prilosec OTC

One per day

$224

Omeprazole 20 mg tablets (nonprescription)

Generic

One per day

$174

Omeprazole 10 mg delayed-release capsules

Prilosec

One per day

$211

Omeprazole 10 mg delayed-release capsules

Generic

One per day

$64

Omeprazole 20 mg delayed-release capsules

Prilosec

One per day

$236

Omeprazole 20 mg delayed-release capsules

Generic

One per day

$58

Omeprazole 40 mg delayed-release capsules

Prilosec

One per day

$374

Omeprazole 40 mg delayed-release capsules

Generic

One per day

$134

Pantoprazole 20 mg delayed-release tablets

Protonix

One per day

$254

Pantoprazole 20 mg delayed-release tablets

Generic

One per day

$70

Pantoprazole 40 mg delayed-release tablets

Protonix

One per day

$232

Pantoprazole 40 mg delayed-release tablets

Generic

One per day

$66

Rabeprazole 20 mg tablets

Aciphex

One per day

$355

1. "Generic" indicates drug sold by generic name. Among PPIs, omeprazole, omeprazole/sodium bicarbonate, lansoprazole, and pantoprazole are available as generic drugs.
2. As typically prescribed.

3. Monthly cost reflects nationwide retail average prices for April 2013, rounded to the nearest dollar. Information was derived by Consumer Reports Best Buy Drugs from data provided by Symphony Health Solutions, which is not involved in our analysis or recommendations. Average monthly cost is based on recommended dosage of one pill daily.

4. Prices for these medications were obtained by Consumer Reports secret shoppers at five major chain pharmacies (CVS, Rite Aid, Target, Walgreens, and Walmart) and local supermarkets across the U.S. in January 2013. The prices from the various stores were averaged to yield per-pill prices, which were then converted into a monthly price.

NOTE: The information contained in the Consumer Reports Best Buy Drugs™ reports is for general informational purposes and is not intended to replace consultation with a physician or other health care professional. Consumers Union is not liable for any loss or injury related to your use of the reports. The reports are intended solely for individual, non-commercial use and may not be used in advertising, promotion, or for any other commercial purpose.


Copyright 2010, Consumers Union of United States, Inc

Heartburn Drugs is a sample topic from the Consumer Reports Health.

To view other topics, please or purchase a subscription.

Learn more.

Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case