Understanding your acid reflux medication

Background: While pharmacological properties of R- and S-enantiomers (mirror-image drugs) can differ, a 2021 systematic review of trials comparing single enantiomers to their mixtures showed that claims of clinical superiority are typically not supported by evidence. Aims: This Therapeutics Letter assesses current evidence comparing clinical effects of dexlansoprazole with lansoprazole, and esomeprazole with omeprazole, and summarizes efficacy and safety findings of previous Therapeutics Letters on PPIs. Methods: We conducted a systematic review of head-to-head randomized controlled trials of proton pump inhibitors (PPIs) comparing dexlansoprazole with lansoprazole, and esomeprazole with omeprazole, for treating gastroesophageal reflux disease (GERD) or erosive esophagitis (EE) in adults. Study quality was assessed using the Cochrane Risk-of-Bias-2 tool. Results: Of 5 trials that compared esomeprazole and omeprazole at equivalent doses for treating GERD or EE, 3 showed no significant difference and 1 favoured omeprazole. The only study favouring esomeprazole was biased because it compared non-equivalent doses. Of 4 trials that compared dexlansoprazole with lansoprazole for GERD or EE, 3 were industry-funded. All trials appeared to be biased, since they compared high-dose (30 or 60 mg) double-release to low-dose (15 or 30 mg) single-release of the R-enantiomer (right-handed molecule). Prescribing of single-enantiomers in British Columbia resulted in patients taking 3 times higher doses of acid-suppression molecules, and paying higher prices. Recommendations: PPIs should not be prescribed at high doses over many years until better long-term evidence of safety is available. Prescribing omeprazole or lansoprazole rather than single-enantiomers would potentially save over 21 million dollars per year in British Columbia, with additional significant savings possible by switching to pantoprazole.