Nexium/Prilosec Interchangability

[Sparda29]

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So a patient comes in with a prescription for Nexium, however it is not covered until the patient goes on Prilosec first.

Let's say the dose for Nexium is 40 mg QD and you cannot contact the MD for a few days. What do you guys usually tell the patient to do? Take prilosec OTC 20 mg QD, or H2-antagonists + antacids until you reach the MD? Or just wait until the MD gets back?

 

[WVUPharm2007]

That's a question that's hard to answer without more perspective. But consider...

Both the R and S isomer of omeprazole have activity at the H-K-ATP receptor, with the S isomer obviously having more affinity. Thus, one could reasonably conclude that at worst, a 2X increase in Omeprazole would cover Esomeprazole. (I.e. 40mg racemic omeprazole vs. 20mg esomeprazole.) In reality, I would think that it's actually a ratio less than 2:1. Perhaps 1.66:1. But to my knowledge, I'm not sure a receptor-isomer focused pharmacodynamic study hasn't been done yet. If any student out there knows of one, do post.

Now in a SPECIFIC case, it is hard to know what is needed without the history of the patient. Has the patient failed therapy with only 20mg of Nexium? Did the patient just start out at 40mg of Nexium as initial therapy from their physician? If they failed 20mg and bumped it up to 40mg, then it may take at LEAST 40mg of omeprazole to even think about covering it. Likely 60mg or higher. Now based upon my subjective experiences, the majority of people taking that much Nexium just started out at that dose as initial therapy. I would tell the patient to TRY the 20mg omeprazole and see what happens. You can't recommend for them to take more than that from a legal perspective because the max OTC dose is 20mg daily.

Personally, I'd see if Protonix or Prevacid was an alternative. My P&T committee substitutes 60mg lansoprazole for 40mg esomeprazole and 40mg pantoprazole. Just changing it to 40mg Protonix would probably be an easier switch off. Inquire about the inclusiveness of the patient's formulary.

But that's me.

 

[Aznfarmerboi]

Agreed. Twice the dose of Prilosec OTC is about equivalent to one dose of Nexium. Not an exact science but something to go by.

 

[MountainPharmD]

That's a question that's hard to answer without more perspective. But consider...

Both the R and S isomer of omeprazole have activity at the H-K-ATP receptor, with the S isomer obviously having more affinity. Thus, one could reasonably conclude that at worst, a 2X increase in Omeprazole would cover Esomeprazole. (I.e. 40mg racemic omeprazole vs. 20mg esomeprazole.) In reality, I would think that it's actually a ratio less than 2:1. Perhaps 1.66:1. But to my knowledge, I'm not sure a receptor-isomer focused pharmacodynamic study hasn't been done yet. If any student out there knows of one, do post.

Now in a SPECIFIC case, it is hard to know what is needed without the history of the patient. Has the patient failed therapy with only 20mg of Nexium? Did the patient just start out at 40mg of Nexium as initial therapy from their physician? If they failed 20mg and bumped it up to 40mg, then it may take at LEAST 40mg of omeprazole to even think about covering it. Likely 60mg or higher. Now based upon my subjective experiences, the majority of people taking that much Nexium just started out at that dose as initial therapy. I would tell the patient to TRY the 20mg omeprazole and see what happens. You can't recommend for them to take more than that from a legal perspective because the max OTC dose is 20mg daily.

Personally, I'd see if Protonix or Prevacid was an alternative. My P&T committee substitutes 60mg lansoprazole for 40mg esomeprazole and 40mg pantoprazole. Just changing it to 40mg Protonix would probably be an easier switch off. Inquire about the inclusiveness of the patient's formulary.

But that's me.

What the hell has happened to you?

 

[Quiksilver]

So a patient comes in with a prescription for Nexium, however it is not covered until the patient goes on Prilosec first.

Let's say the dose for Nexium is 40 mg QD and you cannot contact the MD for a few days. What do you guys usually tell the patient to do? Take prilosec OTC 20 mg QD, or H2-antagonists + antacids until you reach the MD? Or just wait until the MD gets back?

I know that when i have heartburn Im sure not as hell going to just wait til my doctor calls back. I would always try prilosec, which is better then nothing, its also better then tums b/c it has a longer effect. Of course, if the patient is prilosec "resistant" then it probably won't do any good. I would suggest then using a H2 Antagonists and hope for the best. Also counseling on PPI use is also big. Take prilosec 30 minutes before any food! This perhaps could be a reason for resistance.

another option is the discount program that the drug company has, it gives discounts on the copay of the drug. I think you can go online to get it. Perhaps it will help the patient, if its a copay issue.

the question is why are they on nexium? As WVU said, thats the key to the question. There is no all encompassing answer.

Our hospital switches everyone to 40 mg pantoprazole, since i believe that Nexium cannot be given NG tube? We do carry lansoprazole but i forgot as to how we use that.

 

[Sparda29]

Sounds cool.

 

[Farmercyst]

I agree pt history would be a determining factor. I don't have enough experience to know if MDs are writing for PPIs before an adequate trial of H2RAs, but that might be something to find out first. I know we have Prilosec OTC samples that we could give out to last over the weekend, so that could be an option if you have them. Might also find out what they can use that doesn't require trial of omeprazole first. I know medi-cal (CA medicaid) no longer has omeprazole on formulary, instead it's Zegerid and Prevacid(pretty sure on prevacid, might be protonix).

 

[dgroulx]

I interchange all PPI's with whatever is on formulary (usually omeprazole) unless they are on Plavix. One of my hospitals wants Protonix only with Plavix, another says no PPI's at all with Plavix because of the CYP3A4 interaction.

For GERD, or just bad heartburn, OTC Prilosec will work just fine. Counsel to take it on an empty stomach. I always schedule it 1/2 hour before breakfast unless the MD writes for bedtime. I take mine at bedtime and I never have heartburn anymore. My DH takes his 1/2 hour before lunch with the same results.

 

[dgroulx]

Our hospital switches everyone to 40 mg pantoprazole, since i believe that Nexium cannot be given NG tube? We do carry lansoprazole but i forgot as to how we use that.

Prevacid (lansoprazole) Solu-Tabs are for NG tube usage.

 

[Quiksilver]

Prevacid (lansoprazole) Solu-Tabs are for NG tube usage.

they prefer protonix. I don't think its just for ng tubes that they use prevacid.

 

[Praziquantel86]

they prefer protonix. I don't think its just for ng tubes that they use prevacid.

We use lansoprazole just to make suspensions. Real easy procedure. Pantoprazole for everything else.

 

[Sparda29]

Anyone notice that Protonix and generic Protonix are the exact same pill?

 

[Quiksilver]

A

Anyone notice that Protonix and generic Protonix are the exact same pill?

Do you think that is a coincidence?

 

[Sparda29]

A

Do you think that is a coincidence?

Nope, I think it's a scheme by the manufacturers of Protonix to keep making money.

 

[WVUPharm2007]

Nope, I think it's a scheme by the manufacturers of Protonix to keep making money.

That because Wyeth owns the generic company...the original manufacture owning the first generic manufacturer to come out with an AB product happens all the time. Pfizer is the biggest culprit...

 

[kdt110]

20 mg of prilosec = 20 mg of nexium.

 

[kdt110]

Conversion table: http://aeholland.com/ticprotonpump404.pdf