A critical evaluation of proton pump inhibitors in the treatment of gastroesophageal reflux disease.

Proton pump inhibitors (PPIs) are the drugs of choice for treating gastroesophageal reflux disease (GERD). Their superiority to histamine2 receptor antagonists (H2RAs), cisapride, and sucralfate is directly related to their potent and prolonged suppression of gastric acid. The PPIs provide the most rapid relief of GERD symptoms and esophageal healing when compared with standard- or high-dose H2RAs or cisapride. Their superiority over H2RAs has also been demonstrated when used in maintaining esophageal healing and symptom relief. The cost effectiveness of standard-dose PPIs in the treatment of GERD has been well documented. High-dose PPI therapy may benefit patients with atypical GERD symptoms and may also be cost effective. Four PPIs are available in the United States: omeprazole, lansoprazole, rabeprazole, and pantoprazole. All 4 PPIs, when used in recommended dosages, are very effective for the acute and chronic treatment of GERD and demonstrate similar short- and long-term safety profiles. Subtle differences appear to exist, some of which are based on data obtained in vitro or from healthy volunteer studies and others on trends or relatively minor differences observed in selective clinical trials. In most cases, experience has not yet confirmed the clinical importance of these potential differences. The selection of a preferred PPI for a hospital or managed care formulary will most likely be based on the acquisition cost of the drug.