Omeprazole (Monograph)

Brand names: PriLOSEC, Zegerid
Drug class: Proton-pump Inhibitors
- Antiulcer Agents
- Gastric Antisecretory Agents
- Acid-pump Inhibitors
VA class: GA900
Chemical name: 5-Methoxy-2-[[(4-methoxy-3,5-dimethyl-2-pyridinyl)methyl]sulfinyl]-1H-benzimidazole
Molecular formula: C₁₇H₁₉N₃O₃SC₃₄H₃₆MgN₆O₆S₂
CAS number: 73590-58-6

Medically reviewed by Drugs.com on Feb 5, 2024. Written by ASHP.

Introduction

Acid- or proton-pump inhibitor; gastric antisecretory agent.¹ ² ³ ⁴ ⁵ ⁸ ¹³² ²⁰⁷ ²⁰⁸

Uses for Omeprazole

Gastroesophageal Reflux (GERD)

Short-term treatment of symptomatic GERD (e.g., heartburn).¹ ⁵ ⁹⁷ ²⁰⁷ ²⁰⁸

Short-term treatment of erosive esophagitis (endoscopically diagnosed) in patients with GERD.¹ ² ³ ⁴ ⁵ ⁸ ⁹² ⁹³ ⁹⁴ ⁹⁵ ⁹⁶ ⁹⁷ ⁹⁸ ²⁰⁷

Maintain healing and decrease recurrence of erosive esophagitis.¹ ⁹² ⁹³ ⁹⁴ ⁹⁵ ⁹⁶ ²⁰⁷ ²⁰⁸

Short-term self-medication for symptomatic relief of frequent (e.g., 2 or more days a week) heartburn in adults ≥18 years of age.¹⁸⁷

Duodenal Ulcer

Short-term treatment of active duodenal ulcer (endoscopically or radiographically confirmed).¹ ² ³ ⁴ ⁸ ²⁰⁷ ²⁰⁸

Treatment of Helicobacter pylori infection and duodenal ulcer disease.¹ ¹³⁸ Used in conjunction with amoxicillin and clarithromycin (triple therapy) or clarithromycin (dual therapy);¹ ¹³⁸ has been used in other multidrug regimens^{† [off-label]}.²⁷ ²⁸ ²⁹ ³⁷ ³⁸ ³⁹ ⁶¹ ⁶² ⁶⁶ ⁶⁷ ⁷⁵ ⁷⁶ ⁷⁷ ⁷⁸ ⁷⁹ ⁸¹ ⁸² ¹⁰⁶ ¹⁰⁸ ¹¹⁰ ¹¹¹ ¹¹² ¹¹³ ¹¹⁵ ¹³⁸

Gastric Ulcer

Short-term treatment and symptomatic relief of active benign gastric ulcer.¹ ²⁰⁷ ²⁰⁸

Crohn’s Disease-associated Ulcers

Some evidence for use of proton-pump inhibitors (e.g., omeprazole) for gastric acid suppressive therapy as an adjunct in the management of upper GI Crohn’s disease^{† [off-label]}, including esophageal, gastroduodenal, and jejunoileal disease.¹⁹⁰ ¹⁹¹ ¹⁹² ¹⁹⁴ ¹⁹⁵ ¹⁹⁶

Pathologic GI Hypersecretory Conditions

Long-term treatment of Zollinger-Ellison syndrome, multiple endocrine adenomas, or systemic mastocytosis in adults.¹ ² ³ ⁴ ⁵ ⁸ ¹³

Upper GI Bleeding

Used to decrease risk of upper GI bleeding in critically ill patients.²⁰⁷ ²⁰⁸ ²¹¹

Omeprazole Dosage and Administration

Administration

Omeprazole is acid-labile.¹ ²⁰⁷ ²⁰⁸ To avoid decomposition in acidic pH of the stomach, delayed-release capsules and delayed-release oral suspension (Prilosec) contain enteric-coated granules of the drug;¹ ² ⁴ immediate-release capsules and immediate-release oral suspension (Zegerid) contain sodium bicarbonate to protect the drug.²⁰⁷ ²⁰⁸

Oral Administration

Immediate-release Capsules

Swallow intact with a glass of water at least 1 hour prior to a meal.²⁰⁷ Do not use with any other liquid.²⁰⁷ Do not open capsules or mix the contents with food.²⁰⁷

Do not substitute two 20-mg capsules for one 40-mg capsule because the 20-mg and 40-mg capsules contain the same amount of sodium bicarbonate.²⁰⁷

Delayed-release Capsules

Administer orally at least 1 hour before a meal.¹

Swallow capsules intact; do not chew or crush.¹

Antacids may be used concomitantly as needed for pain relief.¹ ³

Alternatively, open capsule and mix contents with 1 tablespoon applesauce; swallow immediately without chewing and with glass of cool water to ensure complete swallowing.¹ Applesauce should not be hot and should be soft enough to swallow without chewing.¹

Delayed-release Tablets

Tablets for self-medication: swallow intact with a glass of water before breakfast; do not chew, crush, or crush in food.¹⁸⁷ ¹⁸⁹

Powder for Immediate-release Oral Suspension

Administer at least 1 hour prior to a meal.²⁰⁷ ²⁰⁸

May use antacids, antacid/alginic acid combinations, histamine H₂-receptor antagonists, or histamine H₂-receptor antagonist and antacid combinations for “breakthrough” symptoms, but efficacy of these preparations has not been established.²⁰⁸

Empty 20- or 40-mg single-dose packet for oral suspension into small cup containing 15–30 mL of water, stir well, and swallow immediately.²⁰⁷ ²⁰⁸ Rinse container with more water and swallow to ensure complete consumption of the dose.²⁰⁷ ²⁰⁸ Do not mix with any other liquid or food.²⁰⁷ ²⁰⁸

Do not substitute two 20-mg packets for one 40-mg packet because the 20- and 40-mg powder for oral suspension packets contain the same amount of sodium bicarbonate.²⁰⁷

Powder for Delayed-release Oral Suspension

Administer at least 1 hour before a meal.¹

Antacids may be used concomitantly.¹

Empty contents of 2.5- or 10-mg single-dose packet into small cup containing 5 or 15 mL, respectively, of water.¹ Stir well, then allow to thicken for 2–3 minutes.¹ Stir again and administer within 30 minutes of preparation.¹ If any material remains in the cup, add additional water, mix, and ingest immediately to ensure complete consumption of the dose.¹

NG Tube

Powder for delayed-release oral suspension: Reconstitute 2.5- or 10-mg single-dose packet with 5 or 15 mL of water, respectively, in a catheter-tipped syringe and shake immediately.¹ Allow mixture to thicken for 2–3 minutes.¹ Shake syringe and administer within 30 minutes through NG or gastric tube (6 French or larger).¹ Refill syringe with additional water (5 or 15 mL, respectively), shake, and flush any remaining drug mixture from the tube.¹

Powder for immediate-release oral suspension: Reconstitute 20- or 40-mg single-dose packet with 20 mL of water, stir well, administer immediately through NG or orogastric tube using appropriately sized syringe.²⁰⁷ ²⁰⁸ Flush the tube with 20 mL of water after administration.²⁰⁷ ²⁰⁸ Temporarily stop continuous enteral feeding via NG or orogastric tube for 3 hours before and 1 hour after administration.²⁰⁷ ²⁰⁸

Dosage

Available as omeprazole and omeprazole magnesium; dosage expressed in terms of omeprazole.¹ ¹⁸⁷

Pediatric Patients

Gastroesophageal Reflux

GERD.

Oral (Delayed-release Capsules or Delayed-release Oral Suspension)

Oral Omeprazole Dosage for Treatment of GERD in Pediatric Patients 1–16 Years of Age1
Body Weight	Omeprazole Dosage
5 to <10 kg	5 mg once daily
10 to <20 kg	10 mg once daily
≥20 kg	20 mg once daily

Administered for 4 weeks in one study.¹ ¹⁹⁸

Treatment of Erosive Esophagitis.

Oral (Delayed-release Capsules or Delayed-release Oral Suspension)

Oral Omeprazole Dosage for Treatment of Erosive Esophagitis in Pediatric Patients 1–16 Years of Age1
Body Weight	Omeprazole Dosage
5 to <10 kg	5 mg once daily
10 to <20 kg	10 mg once daily
≥20 kg	20 mg once daily

On a mg/kg basis, dosage of omeprazole required to heal erosive esophagitis is greater in children than that required in adults.¹ ¹⁹⁷ ¹⁹⁸ In an uncontrolled open-label study, dosages required for healing were 0.7–3.5 mg/kg daily (maximum 80 mg daily) for 3–6 months; about 90% of children healed in the first 3 months, and about 5% required a second course of treatment.¹ ¹⁹⁷ ¹⁹⁸ Dosage of 0.7 mg/kg daily resulted in healing in 44% of children; an additional 28% of the children studied required a dosage of 1.4 mg/kg daily for healing to occur.¹ ¹⁹⁷ ¹⁹⁸

Maintenance of Healing of Erosive Esophagitis.

Oral (Delayed-release Capsules or Delayed-release Oral Suspension)

Oral Omeprazole Dosage for Maintenance Therapy in Pediatric Patients 1–16 Years of Age1
Body Weight	Omeprazole Dosage
5 to <10 kg	5 mg once daily
10 to <20 kg	10 mg once daily
≥20 kg	20 mg once daily

Maintenance therapy continued 2 years in one study.¹ ¹⁹⁸ In an uncontrolled open-label study, maintenance dosages were half the dosages required for initial healing in 54% of children, while 46% required dosage increase (0.7–2.8 mg/kg daily) for all or part of the study.¹ ¹⁹⁸

Adults

GERD

GERD without Erosive Esophagitis

Oral (Immediate-release Capsules or Oral Suspension, Delayed-release Capsules or Oral Suspension)

20 mg once daily for up to 4 weeks.¹ ² ²⁰⁷ ²⁰⁸

Treatment of Erosive Esophagitis

Oral (Immediate-release Capsules or Oral Suspension, Delayed-release Capsules or Oral Suspension)

20 mg once daily until healing occurs (usually within 4–8 weeks);¹ ² ²⁰⁷ ²⁰⁸ 40 mg once daily may be required.² ⁹⁸ May give an additional 4 weeks of therapy (up to 12 weeks for a single course).¹ ² ⁹⁸ ²⁰⁷ If recurs, consider additional 4–8 weeks of therapy.¹ ²⁰⁷

Maintenance of Healing of Erosive Esophagitis

Oral (Immediate-release Capsules or Oral Suspension, Delayed-release Capsules or Oral Suspension)

20 mg once daily.¹ ²⁰⁷ ²⁰⁸ Chronic, lifelong therapy may be appropriate.¹⁴³

Self-medication for Frequent Heartburn

Oral (Delayed-release Tablets)

20 mg daily in the morning for 14 days.¹⁸⁷ ¹⁸⁸ Do not exceed recommended dosage or duration; do not administer more than one course every 4 months.¹⁸⁷ ¹⁸⁸ May relieve symptoms within 24 hours, but 1–4 days may be required for complete relief.¹⁸⁷ ¹⁸⁸ ¹⁸⁹

Duodenal Ulcer

Treatment of Active Duodenal Ulcer

Oral (Immediate-release Capsules or Oral Suspension, Delayed-release Capsules or Oral Suspension)

20 mg once daily until healing occurs (usually within 2–4 weeks); an additional 4 weeks with therapy may be beneficial.¹ ² ²⁰⁷ ²⁰⁸ Patients who responded poorly to histamine H₂-receptor antagonists may require up to 40 mg daily.²

Treatment of Helicobacter pylori Infection and Duodenal Ulcer

Oral (Delayed-release Capsules or Oral Suspension)

Triple therapy: 20 mg twice daily (morning and evening) for 10 days in conjunction with amoxicillin and clarithromycin; additional omeprazole therapy with 20 mg once daily for 18 days recommended if active ulcer present initially.¹

Dual therapy: 40 mg once daily (in the morning) for 14 days in conjunction with clarithromycin; omeprazole 20 mg once daily for additional 14 days recommended if active ulcer present initially.¹

Gastric Ulcer

Treatment

Oral (Immediate-release Capsules or Oral Suspension, Delayed-release Capsules or Oral Suspension)

40 mg once daily for 4–8 weeks.¹ ²⁰⁷ ²⁰⁸

Pathologic GI Hypersecretory Conditions

Zollinger-Ellison Syndrome

Oral (Delayed-release Capsules or Delayed-release Oral Suspension)

60 mg once daily initially.¹ ² Adjust dosage according to patient response and tolerance; continue therapy as long as necessary.¹ ² ¹³ Administer daily dosages >80 mg in divided doses.¹ ¹³ May require dosages of up to 360 mg daily (given in 3 divided doses).¹ ²

Multiple Endocrine Adenomas

Oral (Delayed-release Capsules or Delayed-release Oral Suspension)

Systemic Mastocytosis

Oral (Delayed-release Capsules or Delayed-release Oral Suspension)

Upper GI Bleeding

Reduction of Risk of Upper GI Bleeding in Critically Ill Adults

Oral (Immediate-release Oral Suspension)

Initially, 40 mg followed by 40 mg after 6–8 hours on the first day, then 40 mg once daily for up to 14 days.²⁰⁷ Safety and efficacy for >14 days not established.²⁰⁷

Special Populations

Hepatic Impairment

Consider dosage reduction, particularly in patients receiving long-term therapy for maintenance of healing of erosive esophagitis.¹ ²⁰⁷

Renal Impairment

No dosage adjustment necessary.¹ ²⁰⁷

Asians

Consider dosage reduction, especially in patients receiving long-term therapy for maintenance of healing of erosive esophagitis.¹ ²⁰⁷

Cautions for Omeprazole

Contraindications

Known hypersensitivity to omeprazole, any ingredient in the formulation, or esomeprazole or other substituted benzimidazoles (e.g., lansoprazole, pantoprazole, rabeprazole).¹ ²⁵ ¹³⁹ ²⁰⁷

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity Reactions

Hypersensitivity reactions (e.g., anaphylaxis, angioedema, bronchospasm, interstitial nephritis, urticaria) reported.¹

Warnings/Precautions

Gastric Malignancy

Response to omeprazole does not preclude presence of occult gastric neoplasm.¹ ²⁰⁷ ²⁰⁸

Atrophic Gastritis

Atrophic gastritis reported occasionally with long-term use.¹ ²⁰⁷ ²⁰⁸

Clostridium difficile Infection

Proton-pump inhibitors associated with possible increased (1.4–2.75 times) risk of Clostridium difficile infection, including C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis).³³⁵ ³³⁶ ³³⁹ ³⁴⁰ Many patients also had other risk factors for CDAD.³³⁵ May be severe; colectomy and, rarely, death reported.³³⁵

Use the lowest effective dosage and shortest duration of therapy appropriate for the patient's clinical condition.³³⁵

Consider CDAD if persistent diarrhea develops and manage accordingly; initiate supportive therapy (e.g., fluid and electrolyte management), anti-infective therapy directed against C. difficile (e.g., metronidazole, vancomycin), and surgical evaluation as clinically indicated.³³⁵ ³³⁶

Sodium Bicarbonate

Each 20- and 40- mg conventional immediate-release capsule contains 1100 mg of sodium bicarbonate (304 mg [13 mEq] of sodium), and each 20- and 40-mg single-dose packet of powder for immediate-release oral suspension contains 1680 mg of sodium bicarbonate (460 mg [20 mEq] of sodium).²⁰⁷ Consider sodium content when used in patients requiring restricted salt intake.²⁰⁷

Caution in patients with Bartter’s syndrome, hypokalemia, respiratory alkalosis, and acid-base abnormalities.²⁰⁷ ²⁰⁸ Long-term administration of sodium bicarbonate with calcium or milk may cause milk-alkali syndrome.²⁰⁷ Long-term use of sodium bicarbonate may lead to systemic alkalosis, and increased sodium intake can produce edema and weight increase.²⁰⁷ Sodium bicarbonate is contraindicated in patients with metabolic alkalosis or hypocalcemia.²⁰⁸

Respiratory Effects

Administration of proton-pump inhibitors has been associated with an increased risk for developing certain infections (e.g., community-acquired pneumonia).¹⁹⁹ ²⁰⁰

Bone Fracture

Several observational studies suggest that use of proton-pump inhibitors, particularly in high dosages (i.e., multiple daily doses) and/or for prolonged periods of time (i.e., ≥1 year), may be associated with increased risk of osteoporosis-related fractures of the hip, wrist, or spine.¹ ²¹² ³⁰⁰ ³⁰¹ ³⁰² ³⁰³ ³⁰⁴ ³⁰⁵ Magnitude of risk is unclear;²¹² ³⁰⁰ ³⁰¹ ³⁰² ³⁰³ ³⁰⁴ ³⁰⁵ ³¹⁰ causality not established.³⁰⁵ FDA is continuing to evaluate this safety concern.³⁰⁵

Use the lowest effective dosage and shortest duration of therapy appropriate for the patient’s clinical condition.¹ ²¹² ³⁰¹ ³⁰³ ³⁰⁵ ³⁰⁷

Individuals at risk for osteoporosis-related fractures should receive an adequate intake of calcium and vitamin D; assess and manage these patients’ bone health according to current standards of care.¹ ²¹² ³⁰³ ³⁰⁵ ³⁰⁷

Hypomagnesemia

In patients expected to receive long-term proton-pump inhibitor therapy or in patients currently receiving digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), consider measuring serum magnesium concentrations prior to initiation of prescription proton-pump inhibitor therapy and periodically thereafter.¹ ²⁰⁷ ³¹³ ³¹⁴ ³¹⁶ ³¹⁹ ³²⁶

Hypomagnesemia, symptomatic and asymptomatic, reported rarely in patients receiving long-term therapy (≥3 months or, in most cases, >1 year) with proton-pump inhibitors, including omeprazole.¹ ²⁰⁷ ³¹³ ³¹⁴ ³¹⁵ ³¹⁶ ³¹⁷ ³¹⁸ ³¹⁹ ³²⁰ ³²¹ ³²² ³²³ ³²⁴ ³²⁵ ³²⁶ Serious adverse effects include tetany, seizures, tremors, carpopedal spasm, arrhythmias (e.g., atrial fibrillation, supraventricular tachycardia), and abnormal QT interval.¹ ²⁰⁷ ³¹³ ³¹⁴ ³¹⁵ ³¹⁸ ³¹⁹ ³²¹ ³²² ³²³ ³²⁵ Paresthesia, muscle weakness, muscle cramps, lethargy, fatigue, and unsteadiness may occur.³¹⁶ ³¹⁹ ³²⁰ ³²¹ ³²⁵ Most patients required magnesium replacement and discontinuance of the proton-pump inhibitor.¹ ²⁰⁷ ³¹³ ³¹⁶ ³¹⁷ ³¹⁹ ³²¹ ³²² ³²³ ³²⁴ ³²⁵ ³²⁶ Hypomagnesemia resolved within 1 week (median) following discontinuance and recurred within 2 weeks (median) of rechallenge.³¹³

Cardiovascular Effects

Preliminary safety data from 2 long-term clinical trials comparing esomeprazole or omeprazole with antireflux surgery in patients with severe GERD raised concerns about a potential increased risk of cardiac events (e.g., MI, heart failure, sudden death) in patients receiving these drugs.²¹³ ²¹⁴ ²¹⁵ After reviewing data from these and other studies, FDA has concluded that long-term use of these drugs is not likely to be associated with an increased risk of such cardiac events.²¹³ ²¹⁴ ²¹⁵ FDA recommends that clinicians continue to prescribe and patients continue to use these drugs in the manner described in the manufacturers’ labelings.²¹³ ²¹⁴ ²¹⁵

Specific Populations

Pregnancy

Category C.¹ ²⁰⁷ ²⁰⁸

Lactation

Distributed into milk.¹ ¹³⁹ ²⁰² ²⁰⁷ Discontinue nursing or the drug.¹ ¹³⁹ ²⁰⁷

Pediatric Use

Safety and efficacy of delayed-release capsules or delayed-release oral suspension established for treatment of symptomatic GERD, treatment of erosive esophagitis, and maintenance of healing of erosive esophagitis in pediatric patients 1–16 years of age.¹ ¹⁹⁸ Safety and efficacy not established in infants <1 year of age or for other uses in pediatric patients.¹

Safety and efficacy for self-medication of frequent heartburn not established in children <18 years of age.¹⁸⁷

Safety and efficacy of immediate-release capsules or immediate-release oral suspension not established in pediatric patients <18 years of age.²⁰⁷

Geriatric Use

No substantial differences in efficacy and safety relative to younger adults, but increased sensitivity cannot be ruled out.¹ ²⁰⁷

Hepatic Impairment

Increased bioavailability and decreased clearance.¹ ²⁰⁷ Monitor patients receiving >20 mg daily for possible adverse effects.³ (See Hepatic Impairment under Dosage and Administration.)

Common Adverse Effects

In adults, diarrhea, nausea, constipation, abdominal pain, vomiting, headache, flatulence.¹ ² ³ ²⁰⁷ ²⁰⁸

In pediatric patients, respiratory effects, fever (in children 1–2 years of age), accidental injuries (in children 2–16 years of age); otherwise, adverse effects generally similar to those in adults.¹

Drug Interactions

Metabolized in the liver by CYP isoenzymes, principally CYP2C19, and to lesser extent by CYP3A4.¹ ¹³⁹ Inhibits CYP2C19.¹

Drugs Metabolized by Hepatic Microsomal Enzymes

Potential to prolong elimination of drugs metabolized by oxidation in the liver.¹ ² ²⁰⁷ Interaction reported with drugs metabolized by CYP isoenzymes; monitor and adjust dosage of these drugs if necessary.¹ ²⁰⁷

Drugs that Cause Hypomagnesemia

Potential pharmacologic interaction (possible increased risk of hypomagnesemia).³¹³ Consider monitoring magnesium concentrations prior to initiation of prescription proton-pump inhibitor therapy and periodically thereafter.¹ ³¹³ (See Hypomagnesemia under Cautions.)

Specific Drugs

Drug	Interaction	Comments
Atazanavir	Possible altered oral absorption of atazanavir, resulting in decreased plasma atazanavir concentrations; possible loss of virologic response¹ ²⁰⁷ ²¹⁸	Manufacturers of omeprazole state that concomitant use with atazanavir is not recommended¹ ²⁰⁷ Antiretroviral treatment-naive patients: If a proton-pump inhibitor is used concomitantly with atazanavir, administer ritonavir-boosted atazanavir (atazanavir 300 mg and ritonavir 100 mg once daily with food); administer the proton-pump inhibitor approximately 12 hours before ritonavir-boosted atazanavir²¹⁷ ²¹⁸ For treatment-naive patients, dosage of proton-pump inhibitor should not exceed omeprazole 20 mg daily (or equivalent)²¹⁷ ²¹⁸ Antiretroviral treatment-experienced patients: Concomitant use of proton-pump inhibitors with atazanavir not recommended²¹⁷ ²¹⁸
Benzodiazepines	Potential for altered benzodiazepine metabolism¹ ²⁰⁷	Monitor and adjust benzodiazepine dosage if needed¹ ²⁰⁷
Cilostazol	Increased peak plasma concentrations and AUC of cilostazol and its active metabolite¹	Consider reducing cilostazol dosage (from 100 mg twice daily to 50 mg twice daily)¹
Clarithromycin	Increased plasma concentrations and AUC of omeprazole, clarithromycin, and 14-hydroxyclarithromycin ¹ ²⁰⁷
Clopidogrel	Omeprazole (or esomeprazole) reduces exposure to clopidogrel's active metabolite and decreases platelet inhibitory effects;¹ ²²³ ²²⁴ ²²⁵ ²²⁸ ³⁵⁰ additional data needed to fully elucidate potential clinical consequences (e.g., increased cardiovascular events)²³⁰ ²³⁶ ²³⁷ ²⁴⁰ ²⁴³ ²⁴⁴ ²⁴⁵ ²⁴⁶ ²⁴⁷ ²⁴⁸ ²⁴⁹ ²⁵⁰ ²⁵¹ ²⁵² Dexlansoprazole, lansoprazole, or pantoprazole had less effect on clopidogrel's antiplatelet activity than did omeprazole or esomeprazole²²⁴ ³⁵⁰ ³⁵¹	Avoid concomitant use of omeprazole (or esomeprazole) and clopidogrel¹ ²²⁴ ²³² ²³³ ³¹² Assess risks and benefits of concomitant proton-pump inhibitor use in individual patients²³⁷ ²⁴⁰ ²⁴³ ²⁴⁸ ²⁵⁰ ³¹¹ American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association (ACCF/ACG/AHA) states that GI bleeding risk reduction with concomitant proton-pump inhibitor in patients with risk factors for GI bleeding (e.g., advanced age; concomitant use of warfarin, corticosteroids, or NSAIAs; H. pylori infection) may outweigh potential reduction in cardiovascular efficacy of antiplatelet treatment associated with a drug-drug interaction.³¹¹ In patients without such risk factors, ACCF/ACG/AHA states that risk/benefit balance may favor use of antiplatelet therapy without a proton-pump inhibitor.³¹¹ If concomitant therapy with a proton-pump inhibitor and clopidogrel is deemed necessary, consider using an agent with little or no CYP2C19-inhibitory activity;²²³ ²³⁰ ²³⁴ ³¹² ³⁵⁰ alternatively, consider using a histamine H₂-receptor antagonist (ranitidine, famotidine, nizatidine)²²³ ²²⁴ ²³⁰ ²³⁴ ²⁵¹ but not cimetidine (also a potent CYP2C19 inhibitor)²³² ²³³
Cyanocobalamin	Potential for decreased cyanocobalamin absorption⁸⁶ ⁹⁸ ⁹⁹ ¹⁰⁰ ¹⁰¹	Monitor serum cyanocobalamin concentrations during long-term omeprazole therapy⁹⁹
Cyclosporine	Potential for altered cyclosporine metabolism¹ ²⁰⁷	Monitor and adjust cyclosporine dosage if needed¹ ²⁰⁷
Darunavir	Ritonavir-boosted darunavir: Decreased plasma concentrations of omeprazole; no effect on darunavir concentrations²¹⁷	Ritonavir-boosted darunavir: No dosage adjustments required³⁴⁹
Diazepam	Potential for prolonged diazepam elimination¹ ²⁰⁷
Digoxin	Increased digoxin bioavailability¹ Hypomagnesemia (e.g., resulting from long-term use of proton-pump inhibitors) sensitizes the myocardium to digoxin and, thus, may increase risk of digoxin-induced cardiotoxic effects³¹³ ³³¹	Monitor for manifestations of digoxin toxicity¹ Consider monitoring magnesium concentrations prior to initiation of prescription proton-pump inhibitor therapy and periodically thereafter¹ ³¹³
Disulfiram	Potential for altered disulfiram metabolism¹ ²⁰⁷	Monitor and adjust disulfiram dosage if needed¹ ²⁰⁷
Diuretics (i.e., loop or thiazide diuretics)	Possible increased risk of hypomagnesemia³¹³	Consider monitoring magnesium concentrations prior to initiation of prescription proton-pump inhibitor therapy and periodically thereafter¹ ³¹³
Fosamprenavir	Fosamprenavir with esomeprazole: Increased esomeprazole AUC; did not substantially alter concentrations of amprenavir (active metabolite of fosamprenavir)³⁴⁵ Ritonavir-boosted fosamprenavir with esomeprazole: Did not substantially affect amprenavir or esomeprazole concentrations³⁴⁵	No dosage adjustment required when proton-pump inhibitors used with fosamprenavir (with or without ritonavir)²¹⁷ ³⁴⁵
Gastric pH-dependent drugs (e.g., ampicillin esters, erlotinib, iron salts, ketoconazole)	Omeprazole may alter drug absorption¹ ²⁰⁷
Lopinavir	Lopinavir/ritonavir: No clinically important effect on lopinavir plasma concentrations or AUC²¹⁷ ³⁴⁴	Lopinavir/ritonavir: No dosage adjustment required when proton-pump inhibitors used concomitantly²¹⁷
Methotrexate	Possible delayed clearance and increased serum concentrations of methotrexate and/or its metabolite hydroxymethotrexate; possible methotrexate toxicity¹ ³³³ ³³⁴ Reported mainly with high-dose methotrexate (300 mg/m² to 12 g/m²),¹ ³³³ but also reported with low dosages (e.g., 15 mg per week)³³³	Manufacturer of omeprazole recommends considering temporary discontinuance of proton-pump inhibitor therapy in some patients receiving high-dose methotrexate¹ Some clinicians recommend withholding the proton-pump inhibitor for several days before and after administration of either high-dose or low-dose methotrexate or, alternatively, substituting a histamine H₂-receptor antagonist for the proton-pump inhibitor³³³ ³³⁴
Nelfinavir	Decreased peak serum concentrations and AUC of nelfinavir and its active metabolite¹ ²⁰⁷ ³⁴⁷	Concomitant use not recommended¹ ²⁰⁷
Phenytoin	Potential for prolonged phenytoin elimination¹ ²⁰⁷
Raltegravir	Increased peak plasma concentration and AUC of raltegravir²¹⁷ ³⁴⁸	No dosage adjustment recommended²¹⁷ ³⁴⁸
Rifampin	Potential for decreased omeprazole concentrations¹	Avoid concomitant use¹
Rilpivirine	Decreased plasma concentrations and AUC of rilpivirine²¹⁷ ³⁴³	Concomitant use contraindicated²¹⁷ ³⁴³
Saquinavir	Ritonavir-boosted saquinavir: Increased peak serum concentrations and AUC of saquinavir¹ ²⁰⁷ ²¹⁷	Ritonavir-boosted saquinavir: Monitor for manifestations of saquinavir toxicity; consider reducing saquinavir dosage ¹ ²⁰⁷ ²¹⁷
St. John’s wort (Hypericum perforatum)	Decreased peak serum concentrations and AUC of omeprazole¹	Avoid concomitant use¹
Sucralfate	Possible delayed proton-pump inhibitor absorption and decreased bioavailability¹³⁴	Administer proton-pump inhibitor at least 30 minutes before sucralfate¹³⁴
Tacrolimus	Potential for increased tacrolimus concentrations¹ ²⁰⁷
Tests for neuroendocrine tumors	Increased serum chromogranin A (CgA) concentrations (secondary to omeprazole-induced increase in intragastric pH) may produce false-positive results¹	Temporarily discontinue omeprazole before assessing CgA concentrations and consider repeating test if initial CgA concentrations are high¹
Tipranavir	Ritonavir-boosted tipranavir: Decreased omeprazole plasma concentrations; no effect on tipranavir concentrations²¹⁷	Ritonavir-boosted tipranavir: Increased omeprazole dosage may be required²¹⁷
Voriconazole	Increased peak plasma concentrations and AUC of omeprazole¹ ²⁰⁷	Omeprazole dosage adjustment usually not required but may be considered in patients receiving high dosages (up to 240 mg daily), such as those with Zollinger-Ellison syndrome¹ ²⁰⁷
Warfarin	Potential for decreased warfarin metabolism and changes in prothrombin measures¹ ¹³⁴ ¹³⁹ ²⁰⁷	Monitor prothrombin time and INR¹ ¹³⁴ ¹³⁹ ²⁰⁷

Omeprazole Pharmacokinetics

Absorption

Bioavailability

Absolute bioavailability with 20–40 mg dose is about 30–40%.¹ ²⁰⁷ Bioavailability increases slightly with repeated dosing.¹ ²⁰⁷

Following administration of delayed-release oral suspension, peak concentration and AUC are 88 and 87%, respectively, of values achieved after oral administration of delayed-release capsules.¹

In children 2–5 years of age, AUCs were lower than in children 6–16 years of age or in adults.¹

Onset

Within 1 hour; maximum effect within 2 hours.¹

Duration

Duration of secretion inhibition is up to 72 hours; inhibition is 50% of maximum at 24 hours.¹ Inhibition increases with repeated daily dosing, reaching steady-state plateau at 4 days.¹ After discontinuance, gastric secretion gradually increases over 3–5 days.¹

Food

Rate of absorption is decreased with meals.³ ⁵ Most effective given about 30 minutes before a meal;⁵ ¹⁰⁸ ¹³² bioavailability may be unaffected if given up to 2 minutes before a meal.³

Administration of immediate-release oral suspension 1 hour after a meal decreases peak plasma concentrations (by 62%) and AUCs (by 26%).²⁰⁷ ²⁰⁸

Special Populations

In patients with chronic hepatic disease, bioavailability is increased to 100% due to decreased first-pass effect.¹ ²⁰⁷

In Asians, AUCs increased 4-fold after a 20-mg dose.¹ ²⁰⁷

Distribution

Extent

Omeprazole crosses the placenta and is distributed into milk.¹ ¹³⁹ ²⁰² ²⁰⁷ ²⁰⁹ ²¹⁰

Prolonged binding to gastric parietal proton pump enzyme.¹ ²⁰⁷

Plasma Protein Binding

95%.¹ ²⁰⁷

Elimination

Metabolism

Undergoes first-pass metabolism.¹ ²⁰⁷ Metabolized to inactive metabolites in the liver by CYP isoenzymes, principally CYP2C19, and to lesser extent by CYP3A4.¹ ¹³⁹

Elimination Route

Excreted principally in urine (77%) as metabolites and to a lesser extent in feces.¹ ²⁰⁷

Half-life

0.5–1 hour.¹ ²⁰⁷

Special Populations

In patients with chronic hepatic disease, clearance is decreased, and plasma half-life is increased to almost 3 hours.¹ ²⁰⁷

Stability

Storage

Oral

Delayed-release Capsules

Tight, light-resistant containers at 15–30°C.¹

Immediate-release Capsules

25°C (may be exposed to 15–30°C).²⁰⁷

Powder for Delayed-release or Immediate-release Suspension

Single-dose packets: 25°C (may be exposed to 15–30°C).¹ ²⁰⁷

Tablets for Self-medication

Tight containers at 20–25°C; protect from high heat, humidity, and moisture.¹⁸⁷

Actions

Inhibits basal and stimulated gastric acid secretion.¹ ² ³ ⁴ ⁵ ²⁰⁷
Concentrates in acid conditions of parietal cell secretory canaliculi; forms active sulfenamide metabolite that irreversibly binds to and inactivates hydrogen-potassium ATPase (proton- or acid pump),² ³ ⁵ ¹³² blocking final step in secretion of hydrochloric acid.¹ ² ³ ⁴ ⁵ ⁸ ¹³² ²⁰⁷ Acid secretion inhibited until additional hydrogen-potassium ATPase is synthesized, resulting in prolonged duration of action.² ³ ⁴ ⁵ ⁸ ¹³²
Suppresses H. pylori in patients with duodenal ulcer and/or reflux esophagitis infected with the organism.² Combined therapy with omeprazole and 1 or more appropriate anti-infectives (e.g., amoxicillin, clarithromycin) can effectively eradicate H. pylori gastric infection.¹ ² ⁶⁷ ⁹⁸ ¹³⁸

Advice to Patients

Importance of swallowing delayed-release capsule intact, without crushing or chewing.¹ Importance of taking delayed-release capsule at least 1 hour before a meal.¹
If mixed with applesauce, importance of mixing delayed-release capsule contents with applesauce soft enough to swallow without chewing.¹ Importance of not using hot applesauce.¹ Importance of immediately swallowing mixture with a glass of cool water, without crushing or chewing; importance of not storing for later use.¹
Importance of swallowing immediate-release capsule intact with water and not with other fluid.²⁰⁷ Importance of not opening capsule or mixing the contents with food.²⁰⁷
Importance of taking immediate-release capsule and oral suspension at least 1 hour before a meal.²⁰⁷ ²⁰⁸
Importance of not substituting two 20-mg immediate-release capsules for one 40-mg capsule or two 20-mg powder for immediate-release oral suspension packets for one 40-mg packet.²⁰⁷
Importance of mixing powder for oral suspension in small cup with water, not with other fluids or food.¹ ²⁰⁷ ²⁰⁸ Importance of swallowing suspension immediately, then refilling cup with water and swallowing to ensure complete ingestion of dose.¹ ²⁰⁷ ²⁰⁸
Possible increased risk of Clostridium difficile infection; importance of contacting a clinician if persistent watery stools, abdominal pain, and fever occur.³³⁵
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.¹ Antacids may be used concomitantly with delayed-release capsules or oral suspension as needed for pain relief.¹ Antacids, antacids/alginic acid combinations, histamine H₂-receptor antagonists, or histamine H₂-receptor antagonist and antacid combinations may be used in conjunction with immediate-release oral suspension for “breakthrough” symptoms.²⁰⁸
Importance of advising patients that use of multiple daily doses of the drug for an extended period of time may increase the risk of fractures of the hip, wrist, or spine.¹ ³⁰⁵
Risk of hypomagnesemia; importance of immediately reporting and seeking care for any cardiovascular or neurologic manifestations (e.g., palpitations, dizziness, seizures, tetany).¹ ²⁰⁷
Importance of women informing their clinicians if they are or plan to become pregnant or plan to breast-feed.¹
Importance of following dosage instructions when omeprazole magnesium is administered for self-medication.¹⁸⁷ ¹⁸⁸ Advise patients that they should use the drug for self-medication only as directed for no longer than 14 days of continuous use and that they should not exceed one course of therapy every 4 months.³⁰⁵
Importance of discontinuing use as self-medication and consulting a clinician if heartburn persists or worsens, use of the drug for >14 days is needed, or >1 course of therapy is required every 4 months.¹⁸⁷
Self-medication with omeprazole magnesium is not intended for immediate relief of heartburn; may relieve symptoms within 24 hours, but 1–4 days may be required for complete relief.¹⁸⁷ ¹⁸⁸ ¹⁸⁹ Not intended to treat occasional (e.g., occurring once weekly or less) symptoms or to prevent occasional meal- or beverage-induced heartburn.¹⁸⁷ ¹⁸⁹
Advise patients to consult their clinician before using omeprazole magnesium for self-medication if they have had heartburn for >3 months or are experiencing heartburn with lightheadedness, dizziness, or sweating; chest or shoulder pain with shortness of breath, sweating, lightheadedness, or pain spreading to the arms, neck, or shoulders; frequent chest pain; frequent wheezing (especially with heartburn); unexplained weight loss; nausea or vomiting; or stomach pain.¹⁸⁷
Advise patients not to use omeprazole magnesium for self-medication and to consult a clinician if they have difficulty or pain with swallowing, are vomiting blood, or have bloody or blackened stools.¹⁸⁷
Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Omeprazole
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Oral	Capsules	20 mg	Zegerid	Santarus
		40 mg	Zegerid	Santarus
	Capsules, delayed-release (containing enteric-coated granules)	10 mg*	Omeprazole Delayed-release Capsules
			PriLOSEC	AstraZeneca
		20 mg*	Omeprazole Delayed-release Capsules
			PriLOSEC	AstraZeneca
		40 mg*	Omeprazole Delayed-release Capsules
			PriLOSEC	AstraZeneca
	For suspension, powder	20 mg/packet	Zegerid	Santarus
		40 mg/packet	Zegerid	Santarus

Omeprazole Magnesium
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Oral	For suspension, delayed-release (containing enteric-coated granules)	2.5 mg (of omeprazole) per packet	PriLOSEC	AstraZeneca
		10 mg (of omeprazole) per packet	PriLOSEC	AstraZeneca
	Tablets, delayed-release	20 mg (of omeprazole)	PriLOSEC OTC	Procter & Gamble

† Off-label: Use is not currently included in the labeling approved by the US Food and Drug Administration.

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217. Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents (Mar 29, 2012). From the US Department of Health and Human Services HIV/AIDS Information Services (AIDSinfo) website. http://www.aidsinfo.nih.gov/contentfiles/lvguidelines/glchunk/glchunk_32.pdf

218. Bristol-Myers Squibb. Reyataz (atazanavir sulfate) capsules prescribing information. Princeton, NJ; 2012 Mar.

219. Gilard M, Arnaud B, Cornily JC et al. Influence of omeprazole on the antiplatelet action of clopidogrel associated with aspirin. JACC. 2008; 51:256-60, doi:10.1016/j.jacc.2007.06.064. Accessed 2008 Dec 8. Available from website. http://content.onlinejacc.org/cgi/content/abstract/51/3/256 http://www.ncbi.nlm.nih.gov/pubmed/18206732?dopt=AbstractPlus

220. Pezalla E, Day D, Pulliadath I. Initial assessment of clinical impact of a drug interaction between clopidogrel and proton pump inhibitors. JACC. 2008; 52:1038-9. Letter. http://www.ncbi.nlm.nih.gov/pubmed/18786491?dopt=AbstractPlus

221. MEDCO. New study: A common class of GI medications reduce protection against heart attack in patients taking widely prescribed cardiovascular drug. Franklin Lakes, NJ; 2008 Nov 11. Press release from website. http://www.medco.com

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223. . PPI interactions with clopidogrel revisited. Med Lett Drugs Ther. 2009; 51:13-4.

224. Sanofi-Aventis/Bristol-Myers Squibb. Plavix, (clopidogrel bisulfate) tablets prescribing information. New York, NY; 2011 Dec.

225. Food and Drug Administration. Early communication about an ongoing safety review of clopidogrel bisulfate (marketed as Plavix). Rockville, MD; 2009 Jan 26. From FDA website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm079520.htm

226. Siller-Matula JM, Spiel AO, Lang IM et al. Effects of pantoprazole and esomeprazole on platelet inhibition by clopidogrel. Am Heart J. 2009; 157:148.e1-5.

227. Gilard M, Arnaud B, Le Gal G et al. Influence of omeprazole on the antiplatelet action of clopidogrel associated to aspirin. J Thromb Haemost. 2006; 4:2508-9. http://www.ncbi.nlm.nih.gov/pubmed/16898956?dopt=AbstractPlus

228. Anon. PPI interactions with clopidogrel. Med Lett Drugs Ther. 2009; 51:2-3.

229. Aubert RE, Epstein RS, Teagarden JR et al. Proton pump inhibitors effect on clopidogrel effectiveness: The clopidogrel Medco outcomes study. Circulation. 2008; 118:S_815, Abstract 3998.

230. Lau WC, Gurbel PA. The drug-drug interaction between proton pump inhibitors and clopidogrel. CMAJ. 2009; 180:699-700. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2659824&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/19332744?dopt=AbstractPlus

231. Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. Plavix, (clopidogrel bisulfate) tablets prescribing information. Bridgewater, NJ; 2009 Oct.

232. Food and Drug Administration. Information for heathcare professionals: Update to the labeling of clopidogrel bisulfate (marketed as Plavix) to alert heathcare professionals about a drug interaction with omeprazole (marketed as Prilosec and Prilosec OTC). Rockville, MD; 2009 Nov 17. From FDA website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm190787.htm

233. Food and Drug Administration. Follow-up to the January 26, 2009 Early Communication about an ongoing safety review of clopidogrel bisulfate (marketed as Plavix) and omeprazole (marketed as Prilosec and Prilosec OTC). Rockville, MD; 2009 Nov 17. From FDA website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm190784.htm

234. Juurlink DN, Gomes T, Ko DT et al. A population-based study of the drug interaction between proton pump inhibitors and clopidogrel. CMAJ. 2009; 180:713-8. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2659819&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/19176635?dopt=AbstractPlus

235. Ho PM, Maddox TM, Wang L et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA. 2009; 301:937-44. http://www.ncbi.nlm.nih.gov/pubmed/19258584?dopt=AbstractPlus

236. Norgard NB, Mathews KD, Wall GC. Drug-drug interaction between clopidogrel and the proton pump inhibitors. Ann Pharmacother. 2009; 43:1266-74. http://www.ncbi.nlm.nih.gov/pubmed/19470853?dopt=AbstractPlus

237. Last EJ, Sheehan AH. Review of recent evidence: potential interaction between clopidogrel and proton pump inhibitors. Am J Health Syst Pharm. 2009; 66:2117-22. http://www.ncbi.nlm.nih.gov/pubmed/19923312?dopt=AbstractPlus

238. Stanek EJ, Aubert RE, Flockhart DA et al. A national study of the effect of individual proton pump inhibitors on cardiovascular outcomes in patients treated with clopidogrel following coronary stenting: the Clopidogrel Medco Outcomes Study. Available from website. Accessed 2009 Dec 15. http://www.theheart.org/displayItem.do?primaryKey=967345&type=ppt

239. Dunn S, Macaulay T, Brennan D et al. Baseline proton pump inhibitor use is associated with increased cardiovascular events with and without use of clopidogrel in the CREDO trial. Circulation. 2008; 118:S815. Abstract 3999.

240. Stockl KM, Le L, Zakharyan A et al. Risk of rehospitalization for patients using clopidogrel with a proton pump inhibitor. Arch Intern Med. 2010; 170:704-10. http://www.ncbi.nlm.nih.gov/pubmed/20421557?dopt=AbstractPlus

241. Bhatt DL, Cryer B, Contant CF et al. The COGENT trial. Available from website. Accessed Dec 15, 2009. http://assets.cardiosource.com/Bhatt_COGENT.ppt

242. Rassen JA, Choudhry NK, Avorn J et al. Cardiovascular outcomes and mortality in patients using clopidogrel with proton pump inhibitors after percutaneous coronary intervention or acute coronary syndrome. Circulation. 2009; 120:2322-9. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2818789&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/19933932?dopt=AbstractPlus

243. Juurlink DN. Proton pump inhibitors and clopidogrel: putting the interaction in perspective. Circulation. 2009; 120:2310-2. http://www.ncbi.nlm.nih.gov/pubmed/19933929?dopt=AbstractPlus

244. Varma C. Clopidogrel and proton pump inhibitors: Are the goal posts shifting?. Thromb Res. 2009; :. http://www.ncbi.nlm.nih.gov/pubmed/19939439?dopt=AbstractPlus

245. Sibbing D, Morath T, Stegherr J et al. Impact of proton pump inhibitors on the antiplatelet effects of clopidogrel. Thromb Haemost. 2009; 101:714-9. http://www.ncbi.nlm.nih.gov/pubmed/19350116?dopt=AbstractPlus

246. O’Donoghue ML, Braunwald E, Antman EM et al. Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials. Lancet. 2009; 374:989-97. http://www.ncbi.nlm.nih.gov/pubmed/19726078?dopt=AbstractPlus

247. Cuisset T, Frere C, Quilici J et al. Comparison of omeprazole and pantoprazole influence on a high 150-mg clopidogrel maintenance dose the PACA (Proton Pump Inhibitors And Clopidogrel Association) prospective randomized study. J Am Coll Cardiol. 2009; 54:1149-53. http://www.ncbi.nlm.nih.gov/pubmed/19761935?dopt=AbstractPlus

248. Khalique SC, Cheng-Lai A. Drug interaction between clopidogrel and proton pump inhibitors. Cardiol Rev. 2009 Jul-Aug; 17:198-200.

249. Kapoor JR. Impact of combining proton pump inhibitors and clopidogrel. Am J Cardiol. 2009; 103:1624. http://www.ncbi.nlm.nih.gov/pubmed/19463530?dopt=AbstractPlus

250. Rude MK, Chey WD. Proton-pump inhibitors, clopidogrel, and cardiovascular adverse events: fact, fiction, or something in between?. Gastroenterology. 2009; 137:1168-71. http://www.ncbi.nlm.nih.gov/pubmed/19635603?dopt=AbstractPlus

251. Kushner FG, Hand M, Smith SC et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009; 120:2271-306. http://www.ncbi.nlm.nih.gov/pubmed/19923169?dopt=AbstractPlus

252. Chua D, Lo A, Jung J. Evidence for interaction between clopidogrel and proton-pump inhibitors. Am J Health Syst Pharm. 2010; 67:604-5; author reply 605-6. http://www.ncbi.nlm.nih.gov/pubmed/20360584?dopt=AbstractPlus

300. Vestergaard P, Rejnmark L, Mosekilde L. Proton pump inhibitors, histamine H2 receptor antagonists, and other antacid medications and the risk of fracture. Calcif Tissue Int. 2006; 79:76-83. http://www.ncbi.nlm.nih.gov/pubmed/16927047?dopt=AbstractPlus

301. Corley DA, Kubo A, Zhao W et al. Proton pump inhibitors and histamine-2 receptor antagonists are associated with hip fractures among at-risk patients. Gastroenterology. 2010; 139:93-101. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2902649&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/20353792?dopt=AbstractPlus

302. Yu EW, Blackwell T, Ensrud KE et al. Acid-suppressive medications and risk of bone loss and fracture in older adults. Calcif Tissue Int. 2008; 83:251-9. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2596870&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/18813868?dopt=AbstractPlus

303. Gray SL, LaCroix AZ, Larson J et al. Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women’s Health Initiative. Arch Intern Med. 2010; 170:765-71. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=4240017&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/20458083?dopt=AbstractPlus

304. Targownik LE, Lix LM, Metge CJ et al. Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ. 2008; 179:319-26. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2492962&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/18695179?dopt=AbstractPlus

305. Food and Drug Administration. Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. May 25, 2010. From FDA web site. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm

307. Yang YX, Metz DC. Safety of proton pump inhibitor exposure. Gastroenterology. 2010; :.

308. Targownik LE, Lix LM, Leung S et al. Proton-pump inhibitor use is not associated with osteoporosis or accelerated bone mineral density loss. Gastroenterology. 2010; 138:896-904. http://www.ncbi.nlm.nih.gov/pubmed/19931262?dopt=AbstractPlus

310. Kaye JA, Jick H. Proton pump inhibitor use and risk of hip fractures in patients without major risk factors. Pharmacotherapy. 2008; 28:951-9. http://www.ncbi.nlm.nih.gov/pubmed/18657011?dopt=AbstractPlus

311. Abraham NS, Hlatky MA, Antman EM et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. JACC. 2010; 56: Published online Nov 8, 2010.

312. Food and Drug Administration. Information on clopidogrel bisulfate (marketed as Plavix). Rockville, MD; 2010 Oct 27. From FDA website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm190836.htm

313. US Food and Drug Administration. FDA drug safety communication: Low magnesium levels can be associated with long-term use of proton pump inhibitor drugs (PPIs). Rockville, MD; 2011 March 2. From FDA website. http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm

314. US Food and Drug Administration. Proton pump inhibitor drugs (PPIs): Drug safety communication- Low magnesium levels can be associated with long-term use. Rockville, MD; 2011 March 2. From FDA website. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm245275.htm

315. Hoorn EJ, van der Hoek J, de Man RA et al. A case series of proton pump inhibitor-induced hypomagnesemia. Am J Kidney Dis. 2010; 56:112-6. http://www.ncbi.nlm.nih.gov/pubmed/20189276?dopt=AbstractPlus

316. Regolisti G, Cabassi A, Parenti E et al. Severe hypomagnesemia during long-term treatment with a proton pump inhibitor. Am J Kidney Dis. 2010; 56:168-74. http://www.ncbi.nlm.nih.gov/pubmed/20493607?dopt=AbstractPlus

317. Furlanetto TW, Faulhaber GA. Hypomagnesemia and Proton Pump Inhibitors: Below the Tip of the Iceberg. Arch Intern Med. 2011; :. http://www.ncbi.nlm.nih.gov/pubmed/21555654?dopt=AbstractPlus

318. Fernández-Fernández FJ, Sesma P, Caínzos-Romero T et al. Intermittent use of pantoprazole and famotidine in severe hypomagnesaemia due to omeprazole. Neth J Med. 2010; 68:329-30. http://www.ncbi.nlm.nih.gov/pubmed/21071783?dopt=AbstractPlus

319. Mackay JD, Bladon PT. Hypomagnesaemia due to proton-pump inhibitor therapy: a clinical case series. QJM. 2010; 103:387-95. http://www.ncbi.nlm.nih.gov/pubmed/20378675?dopt=AbstractPlus

320. Shabajee N, Lamb EJ, Sturgess I et al. Omeprazole and refractory hypomagnesaemia. BMJ. 2008; 337:a425. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2483862&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/18617497?dopt=AbstractPlus

321. . In brief: PPI’s and hypomagnesemia. Med Lett Drugs Ther. 2011; 53:25.

322. Cundy T, Dissanayake A. Severe hypomagnesaemia in long-term users of proton-pump inhibitors. Clin Endocrinol (Oxf). 2008; 69:338-41. http://www.ncbi.nlm.nih.gov/pubmed/18221401?dopt=AbstractPlus

323. Broeren MA, Geerdink EA, Vader HL et al. Hypomagnesemia induced by several proton-pump inhibitors. Ann Intern Med. 2009; 151:755-6. http://www.ncbi.nlm.nih.gov/pubmed/19920278?dopt=AbstractPlus

324. Metz DC, Sostek MB, Ruszniewski P et al. Effects of esomeprazole on acid output in patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion. Am J Gastroenterol. 2007; 102:2648-54. http://www.ncbi.nlm.nih.gov/pubmed/17764495?dopt=AbstractPlus

325. Kuipers MT, Thang HD, Arntzenius AB. Hypomagnesaemia due to use of proton pump inhibitors--a review. Neth J Med. 2009; 67:169-72. http://www.ncbi.nlm.nih.gov/pubmed/19581665?dopt=AbstractPlus

326. Epstein M, McGrath S, Law F. Proton-pump inhibitors and hypomagnesemic hypoparathyroidism. N Engl J Med. 2006; 355:1834-6. http://www.ncbi.nlm.nih.gov/pubmed/17065651?dopt=AbstractPlus

331. GlaxoSmithKline. Lanoxin (digoxin) tablets prescribing information. Research Triangle Park, NC; 2009 Aug.

333. Bezabeh S, Mackey AC, Kluetz P et al. Accumulating evidence for a drug-drug interaction between methotrexate and proton pump inhibitors. Oncologist. 2012; 17:550-4. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3336837&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/22477728?dopt=AbstractPlus

334. Horn JR, Hansten PD. Methotrexate and proton pump inhibitors. Pharm Times. 2012; 78(4). Published online 2012 Apr 9. http://www.pharmacytimes.com/publications/issue/2012/April2012/Methotrexate-and-Proton-Pump-Inhibitors

335. Food and Drug Administration. Drug safety communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs). Rockville, MD; 2012 Feb 8. From FDA website. Accessed 2012 May 3l. http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm

336. Cohen SH, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010; 31:431-55. http://www.ncbi.nlm.nih.gov/pubmed/20307191?dopt=AbstractPlus

337. Shah S, Lewis A, Leopold D et al. Gastric acid suppression does not promote clostridial diarrhoea in the elderly. QJM. 2000; 93:175-81. http://www.ncbi.nlm.nih.gov/pubmed/10751237?dopt=AbstractPlus

338. Leonard AD, Ho KM, Flexman J. Proton pump inhibitors and diarrhoea related to Clostridium difficile infection in hospitalised patients: a case-control study. Intern Med J. 2012; 42:591-4. http://www.ncbi.nlm.nih.gov/pubmed/22616966?dopt=AbstractPlus

339. Kwok CS, Arthur AK, Anibueze CI et al. Risk of Clostridium difficile Infection With Acid Suppressing Drugs and Antibiotics: Meta-Analysis. Am J Gastroenterol. 2012; 107:1011-9. http://www.ncbi.nlm.nih.gov/pubmed/22525304?dopt=AbstractPlus

340. Dial S, Delaney JA, Barkun AN et al. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA. 2005; 294:2989-95. http://www.ncbi.nlm.nih.gov/pubmed/16414946?dopt=AbstractPlus

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347. ViiV Healthcare. Viracept (nelfinavir mesylate) tablets and oral powder prescribing information. Research Triangle Park, NC; 2012 Apr.

348. Merck Sharp & Dohme. Isentress (raltegravir) film-coated tablets and chewable tablets prescribing information. Whitehouse Station, NJ; 2012 Apr.

349. Janssen. Prezista (darunavir) prescribing information. Titusville, NJ; 2012 Jun.

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