Relative potency of proton-pump inhibitors, Helicobacter pylori therapy cure rates, and meaning of double-dose PPI

Background Helicobacter pylori treatment recommendations often recommend use of double-dose PPI or greater. This is confusing because PPIs very markedly in relative potency such that a double dose of one may not even be equivalent to the single dose of another. Objective To relate the concept of double-dose to specific amounts of the different PPIs Methods We used data standardizing PPI potency in terms of the duration of intragastric pH >4/24 hours (pH4-time) to rank PPIs. Relative potency varies from 4.5 mg omeprazole equivalents (20 mg pantoprazole) to 72 mg omeprazole equivalents (40 mg rabeprazole). Results We defined PPI dosing for H. pylori therapy as low dose (eg, approximately 20 mg omeprazole equivalents, b.i.d.), high or double dose as approximately 40 mg omeprazole equivalents, b.i.d.) and high dose as approximately 60 mg omeprazole equivalents, b.i.d.). For example, standard double dose PPI would thus be 40 mg of omeprazole, 20 mg of esomeprazole or rabeprazole, 45 mg of lansoprazole, or 120 mg of pantoprazole each given b.i.d. Conclusions Simply doubling the dose of any PPI achieves markedly different effects on pH4-time. However, PPIs can be used interchangeably and cost effectively based on their omeprazole equivalency.