PROTON PUMP

INHIBITOR
Farmakokinetik Proton Pump Inhibitor
 Optimal Timing of PPI Dose
DOSING: ADMINISTER PPI:
QD 30 minutes before breakfast
BID 30 minutes before breakfast & evening meal
Reimer et al. Gastro 2009; 137: 80-87
• Ensures that maximum plasma concentration of PPI coincides with
the activation of proton pumps

Results of a recent survey:

More than one-third of all primary care
physicians fail to educate patients
properly on the timing of PPI dosing

Chey Am J Gastroenterol 2005;100:1237.

Reimer et al. Gastro 2009; 137: 80-87
 Stopping a PPI: Rebound Acid
• High Gastrin Levels
• Rebound Acid
• Step down therapy?
• Warn patients of symptoms
• Advise PRN H2 blocker
therapy

Reimer et al. Gastro 2009; 137: 80-87

Niklasson et al. Am J Gastro 2010; 105: 1531-1537.
 Overuse of PPI
■ Retrospective, chart review of non-ICU admits1
■ 22% received stress ulcer prophylaxis
■ 54% of those were discharged home on it
■ Retrospective chart review of nursing home admits2
■ 50% did NOT have an appropriate diagnosis for PPI
■ Retrospective chart review of C.diff positive patients3
■ 63% of did NOT have valid indication for PPI
■ Retrospective chart review of cirrhotics + SBP4
■ 47% did NOT have valid reason for PPI
1. Heidelbaugh et al. Am J Gastro 2006; 101: 2200-2205
2. Glew et al. J Am Med Dir Assoc 2007; 9:280-281
3. Choudhry et al. QJM 2008; 101:445-448.
4. Bajaj et al. Am J Gastro, 2009; 104: 1130-1134.
 PPI interaction with Clopidogrel
■ Clopidogrel is a prodrug that is converted to an active metabolite
which irreversibly binds to the platelet P2Y12 receptor, blocking
activation and aggregation
■ Active metabolite formed via cytochrome P450 system
■ Certain PPIs inhibit the cytochrome P450 2C19 pathway and may
interfere with conversion of clopidogrel to the active form2-4
■ Newer studies question this finding?
■ Pantoprazole studied and no increased risk

1. Khalique et al. Cardiology in Review 2009; 17: 198-200

2. Gilard, et al. J Am Coll Cardiol 2008; 51: 256–260
3. Sibbing et al. Thromb Haemost 2009; 101: 714-719
4. O’Donaghue et al. Lancet 2009; 374:989-997