Clinical Question: Is there any difference between proton pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD)?

Setting: Various (meta-analysis)

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: This meta-analysis identified all double-blind randomized controlled trials comparing one PPI with another for the treatment of GERD, using endoscopic healing as the reference standard for treatment success. A total of 19 studies, most lasting four weeks, with more than 9,000 patients were identified. No difference was found for the following comparisons: pantoprazole (Protonix) 40 mg versus omeprazole (Prilosec) 20 mg; pantoprazole 20 mg versus omeprazole 20 mg; lansoprazole (Prevacid) 30 mg versus omeprazole 20 mg; lansoprazole 15 mg versus omeprazole 20 mg; lansoprazole 30 mg versus omeprazole 40 mg; lansoprazole 30 mg versus pantoprazole 40 mg; rabeprazole (Aciphex) 20 mg versus omeprazole 20 mg; rabeprazole 10 mg versus omeprazole 20 mg; and omeprazole 20 mg versus esomeprazole (Nexium) 20 mg. Only one comparison found a statistically significant difference between groups in the treatment of GERD: esomeprazole 40 mg versus omeprazole 20 mg (80 versus 67 percent response rate; P = .04; number needed to treat = 7). However, as noted above, a comparison in 1,306 patients of equivalent doses of 20 mg esomeprazole versus 20 mg omeprazole found no difference in endoscopic healing. The response rates for omeprazole 20 mg in the two studies comparing it with esomeprazole 40 mg were 65 and 67 percent—considerably lower than in other comparisons looking at this dose, in which the success rate was between 70 and 91 percent. This would make esomeprazole look more effective in comparison. Although this comparison has never been made directly, it seems highly likely that 40 mg omeprazole ($40 per month over the counter) would be similar in effectiveness to 40 mg of esomeprazole ($142 per month).

Bottom Line: There is no significant difference between equivalent doses of PPIs, including equivalent doses of esomeprazole and omeprazole. The decision to choose one over another should be based first on cost and second on individual patient response. (Level of Evidence: 1a)