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Esomeprazole vs. Omeprazole for Patients with GERD

Proton-pump inhibitors (PPIs) form the recognized cornerstone of therapy for gastroesophageal reflux disease (GERD). Sustained maintenance of pH higher than 4 has correlated with prompt resolution of GERD symptoms and high rates of esophagitis healing. To date, none of the newer PPIs -- lansoprazole, rabeprazole, or pantoprazole -- have proven significantly better than omeprazole at maintaining pH higher than 4, when clinically relevant endpoints were used. Compared with omeprazole, its S-isomer (esomeprazole) displays lower first-pass hepatic metabolism and slower plasma clearance; this results in higher plasma concentration and highly effective inhibition of gastric acid secretion.

In a double-blind, crossover study, Swedish investigators randomized 38 patients with symptoms of GERD to 1 of 3 once-daily treatments for 5 days: 40 mg esomeprazole, 20 mg esomeprazole, or 20 mg omeprazole. A washout period of at least 2 weeks was required before crossover; 24-hour gastric pH and pharmacokinetic data were assessed at day 5 for each arm of the study.

According to per-protocol analysis for 36 patients, 40-mg and 20-mg esomeprazole maintained mean gastric pH higher than 4 for 17 hours (P (less than) 0.001) and 13 hours (P (less than) 0.01), respectively, versus 11 hours for omeprazole. Compared with the 24-hour mean gastric pH for omeprazole (3.6), mean pH levels were significantly higher for esomeprazole: 40 mg (4.9, P (less than) 0.001) and 20 mg (4.1, P (less than) 0.01). Area under the curve (AUC) for plasma-concentration time was 500 percent higher for 40-mg esomeprazole and 80 percent higher for 20-mg esomeprazole compared with omeprazole. There was less interpatient variability in AUC and gastric pH data with esomeprazole than with omeprazole.

Comment: The gastric pH data from this study show a clear benefit with esomeprazole versus omeprazole. Gastric pH is an intermediate endpoint, however, and is meaningless unless it correlates with improved clinical outcomes. As yet unpublished clinical trial results suggest that pH control will correlate with clinical improvements. Interpatient variability is a problem with PPIs because of unpredictable variation in cytochrome P450 2C19, which mediates the major metabolic pathway for this class. Because esomeprazole is less dependent on this pathway, it should offer a more predictable therapeutic advantage in all patients.

— DA Johnson

Published in Journal Watch Gastroenterology September 11, 2000

Citation(s):

Lind T et al. Esomeprazole provides improved acid control vs. omeprazole in patients with symptoms of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2000 Jul 14 861-867.

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• esomeprazole vs. omeprazole for patients with gerd.
  a brimsn, 9 Jul 2009 7:09 AM EST
  I have suffered with gerd from a teenager i am now 51, i was diagnosed with a hiatus hernia when... [more]
• Poorly designed study
  Jose Eusebio, MD, Carolinas Healthcare System, 12 Jul 2009 6:32 PM EST
  Esomeprazole is the purified L enantiomer of omeprazole (which contains both R- and L-enantiomers). 20 mg of omeprazole contains 10... [more]
• re: a brimsn, 10 Jul 2009 2:46 PM EST
  N. L Lyon, 18 Jul 2009 10:38 AM EST
  The exact same thing just happened to me. In fact it happened 2 years ago as well and my doctor... [more]