The chief ends of developing a Drug Formulary are to develop and implement policies on drug choice, rating, procurance, usage of safe drugs and to circulate dependable drug information to optimise patient attention through rational choice and usage of drugs and at the same clip to guarantee choice drug usage and cost effectual prescribing among doctors ( Savelli et al. , 1996 ) . Too long and confounding – revision, restructure

The quickly lifting cost of drug therapy is a concern to healthcare supplier in developing states such as Malaysia. At least RM 1,510 million was spent yearly in the procurance of drugs entirely for the public infirmaries throughout Malaysia ( MOH, 2008 ) . The authorities is happening it difficult to subsidise this big disbursement. The debut of new drugs which often offer merely fringy betterments over bing therapies but at well increased cost does lend to the heavy disbursement on drugs ( Kessler et al. , 1994 ) . One agency of commanding the overall drug outgo is through the development of drug formulary. Rational choice of drugs through a structured and rigorous choice procedure will merely let medicines which are listed to be prescribed. Reducing the figure of drug entities of the same curative category with lone little differences in footings of clinical effectivity and inauspicious consequence can foster aid in incorporating cost ( WHO, 2003 ) .

2.1 Curative permutation

A survey on discriminatory listing of a individual drug within a drug category was done in the Canada Forces ( CF ) in 2003 to command drug procurance cost. An experimental cohort survey was performed utilizing the database in the Canadian Forces Pharmacy and a entire figure of 4738 PPI users who receive more than 1 PPIs between 1 January 2004 – 31 December 2004 were evaluated to explicate the usage form of PPIs. The survey selected pantoprazole as the most preferable agent in the PPI category based on clinical grounds, handiness of dose signifiers and costs while taking esomeprazole, Prevacid, omeprazole and rabeprazole from the CF Drug Benefit List. Surveies showed that really fringy difference in efficaciousness exist between PPIs when prescribed at tantamount doses ( Amidon et al. , 2000 ; Gearson et al. , 2000 ) . About 87 % ( n=4112 ) were prescribed pantoprazole English while 13.2 % ( n=626 ) received other PPIs. The grounds for those prescribed with other PPI drugs other than pantoprazole were ‘failure to react ‘ , and side effects with pantoprazole. The CF Pharmacy spent Can $ 214,451.98 for the twelvemonth from 2003 to 2004 for pantoprazole entirely, taking over 50 % of cost associated with the PPI category of Can $ 431,504.42 which includes PPI drugs other than pantoprazole and the carrying up of endovenous pantoprazole in standardised military medical kits for usage during deployment ( Ma et al. , 2008 ) . Therefore, cost nest eggs with curative permutation will merely be achieved with rigorous policies and full conformity from doctors.

2.2 Drug Formulary

The conventional manner of developing a formulary system normally involve a procedure whereby the medical staff of an establishment, working through a Formulary and Therapeutics Committee, manages and evaluates, and selects from the legion available drug merchandises that are considered most efficacious, safe, and cost effectual. It is a mechanism to streamline procurance activities, minimise costs and optimise patient attention ( Savelli et al. , 1996 ) .

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The MOH Drug Formulary is one illustration of drug pharmacopeia developed utilizing the conventional method. The MOH Drug Review Panel which comprise of the Director General of Health Malaysia ( president ) , the Deputy Director General of Health ( Medical Services ) , the Director of Pharmaceutical Services, 8 Advisers in Public Service, 2 Pharmacists in Public Service and a Senior Pharmacist in Public Service ( secretary ) will reexamine and update the drug listed in the formulary from clip to clip to guarantee that a comprehensive, evidence-based and dynamic list of drugs is available for bar and intervention of patients. The MOH Drug List Review Panel will run into two to three times per twelvemonth to see proposals received from the States/Institution Drug Committees. The panel is assisted by 17 Technical Drug Working Committees from assorted specialised subjects ( MOH Drug Formulary Manual, 2008 ) . The bing formulary system employs a badly very clip devouring and non so crystalline process to finish an blessing and/or disapproval application.

In order to do the bing procedure more nonsubjective and transparent, a flexible and rational tool that exclude emotional factors, publicizing influence or even cost involvement can be developed. This tool can besides be able to be used for any rating that requires re-assessment with clip or provides easiness of updating to suit alterations in the context in which choice determinations are being made. This tool will be of great aid to the Formulary and Therapeutic Committee particularly in determination procedure as it becomes clear on which criteria the determinations are based on.

2.3 Drug choice system

Many drugs choice tools such as the Pharmaceutical Product Drug Differential Evaluation ( PPDEM ) , Comparative Use of Resource Evaluation Model ( CURE ) , System of Objectified Judgement Analysis ( SOJA ) and Formulary Analysis have been developed and used for formulary intents worldwide ( Karr, 2000 ; Moore et al. , 2002, Janknegt et al. , 1997 ) .

Drug choice methods should be able to help in supplying optimum drug therapy to all patients through the development of standard intervention guidelines, to objectively measure clinical informations of new drugs proposed for usage in infirmaries, to forestall unneeded duplicate of drugs, to develop list of drugs accepted for procurance and usage in the infirmary, to urge and O.K. add-ons and omissions from the formulary, to carry on on-going drug usage rating plans ( Savelli et al. , 1996 ) .

PPDEM is an analytical tool to back up ratings on drug choice. PPDEM is normally used to separate choice standards of drugs belonging to the same curative category of drugs which were used to handle a peculiar prevalent disease ( Karr, 1994 ; Rawlins, 1999 ) .

CURE is a similar flexible theoretical account for drug rating and choice that can distinguish drugs within the same curative category which includes standards such as efficaciousness, safety, side effects and cost. The advantage of CURE over PPDEM is the inclusion of an extra standard called clime for alteration. Climate for alteration includes the experience factor of the prescriber, infirmary preparedness to alter to a new drug, patient acceptableness of altering to new drugs when the current drugs works good on them, resource benefit where by altering to a new drugs with lone fringy cost nest eggs is gained and frequence of reappraisal particularly when new drugs are launched at a fast gait, the susceptibleness of the prescriber and patient to change the prescribing pattern. CURE theoretical account provides determination shapers with an analytical tool to back up ratings on drug choice and besides intended to excite treatment or argument by determination shapers and may help in supplying a suited mechanism for bring forthing the determination itself. CURE theoretical account is auditable, flexible and accommodate alterations.

A Formulary Analysis on angiotonin receptor blockers ( ARBs ) was done in the Sheffield Teaching Hospital Trust, England. Six ARBs which consist of candersartan, eprosartan, irbersartan, losartan, telmisartan and Diovan were reviewed and evaluated by a panel of heart specialists, a doctor and a druggist. Nine choice standards were developed as a comparing model between these drugs. A comparative weight was assigned to each standard by the panel. Each ARB was consistently evaluated against each standard and tonss were calculated. Consequences obtained were presented and recognized by the infirmary ‘s P & A ; T commission. Losartan was ranked the highest ( 707 ) , followed by Diovan ( 611 ) and candersartan ( 610 ) ( Moore et al. , 2002 ) .

Another structured attack to the choice of drugs for formulary inclusion was of System of Objectified Judgement Analysis ( SOJA ) which was foremost developed in The Netherlands for the rating of soporifics, NSAIDs and ARBs. The standard included in the method for soporifics drugs choice were clinical efficaciousness ( 300 points ) , inauspicious effects ( 250 points ) , clinical certification ( 150 points ) , cost ( 120 points ) , pharmacokinetic belongingss ( 80 points ) , toxicity ( 50 points ) , drug interactions ( 30 points ) and the figure of tablet strengths available ( 20 points ) .

A little alteration of the SOJA system was so developed which was tested on the choice of ACE Inhibitors ( ACEIs ) in Northern Ireland. ACEIs included in the survey were Capotens, cilazapril, Vasotec, fosinopril, imidapril, Prinival, moexipril, perindopril, quinalapril and Mavik. The comparative weighting for each drug were assigned to each standard for every drugs were determined by a panel of expert which consisted of a adviser cardiologists, a general practicians, two druggists, a regional pharmaceutical procurance director, a infirmary pharmaceutical services director and a wellness economic expert. The choice standards for ACEI were based on grounds based pharmacotherapeutic rating for all the ACEIs, safety and cost impact. Relative weightings were so assigned to the standards by the adept panel. The end point hiting system incorporating the choice standards every bit good as the weighting tonss was validated by 103 cardinal determination shapers and secondary attention advisers in Northern Ireland, the association of British Pharmaceutical Industry, the British General Manufacturing Association and the Parallel Pharmaceutical Distribution Industry. These prescribers were asked to notice on the allotment of the tonss and to alter the tonss and give importance to the standards by adding and taking standards. The last measure involved marking of the single ARBs by 33 expert panels ( 7 heart specialists, 6 nephrologists, 8 druggists 2 endocrinologists, 2 internal medical specialty advisers, 1 senior geriatrician and 7 determination shapers ) utilizing published literature every bit good as from both proprietary and generic makers within the category of ACEIs. Merely 5 ACEIs i.e. Mavik, Prinival, Altace, Vasotec, fosinopril scored the highest and were included in the drug pharmacopeia. Modified SOJA allows drug choice within a drug category across a scope of indicants and confers clinical effectivity primacy over cost ( Alabbadi et al. , 2006 ) .

SOJA, modified SOJA, Formulary Analysis, PPDEM and CURE are hiting systems that can be used to measure and so re-evaluate drugs in the same curative category whenever there is new update on the drugs ( Karr, 1994 ; Rawlins, 1999 ; Janknegt et al. , 1997 ) . The sum-up of each tools were demonstrated in Tables 2.1, 2.2 and 2.3.

Table 2.1: Comparison between drug choice methods in footings of standards

Drug Selection Method



Efficacy, safety, cost


Efficacy, safety, cost, clime for alterations

Formulary Analysis

Efficacy, safety, cost


Documentation, efficaciousness, safety, cost

MOH Drug Formulary

Efficacy, safety, cost

Table 2.2: Comparison between drug choice methods in footings of judge

Drug Selection Method



Expert panel which consists of advisers and health care suppliers


Expert panel which consists of advisers and health care suppliers

Formulary Analysis

Expert panel which consists of advisers and health care suppliers


Expert panel which consists of advisers and health care suppliers

MOH Drug Formulary

Expert panel which consists of advisers and health care suppliers

Table 2.3: Comparison between drug choice methods in footings of weightage

Drug Selection Method



Arbitrary ; Depend on the grade of importance in the rating procedure. The more of import standards will delegate a higher mark.

Entire score:100


Arbitrary ; Depend on the grade of importance in the rating procedure. The more of import standards will delegate a higher mark.

Entire mark: 100

Formulary Analysis

Arbitrary ; Depend on the grade of importance in the rating procedure. The more of import standards will delegate a higher mark.

Entire score:1000


Arbitrary ; Depend on the grade of importance in the rating procedure. The more of import standards will delegate a higher mark.

Entire mark: 1000

MOH Drug Formulary

Highly dependant on panellists ‘ experiences, evidence-based information

No mark points.

Gastroesophageal reflux disease ( GERD ) any enumeration

Gastroesophageal reflux disease ( GERD ) is the retrograde motions of stomachic contents from the tummy into the gorge which can do inflame and harm to the linng of the gorge. The regurgitate liquid normally contains acerb and pepsin. GERD symptoms can change from mild to severe ; from typical symptoms include pyrosis, belching, hypersalivation, and regurgitation without endoscopically demonstrated esophagitis, to severe esophageal mucosal harm such as peptic stenosis and Barrett ‘s metaplasia ( Devault & A ; Castell, 1999 ) .

The normal map of lower gorge sphincter ( LES ) is to bring forth contraction and shutting of the transition from the gorge into the tummy. This shutting prevents reflux. When nutrient is swallowed, the LES relaxes foe a few seconds to let the nutrient to base on balls from the gorge into the tummy, and so contracts and stopping points once more. Weak contraction of the LES and transeunt LES relaxation which caused unnatural relaxation of LES are disfunction of the LES that cause reflux. Other factors that may lend to GERD are hiatal hernias, gestation and fleshiness ( Devault & A ; Castell, 2005 ) .

The ends of intervention for GERD include:

alleviating symptoms

healing of esophagitis

forestalling farther symptoms and complications.

Prevention and return of the disease

There are two rating strategy that has been used in endoscopic appraisal in comparative clinical surveies. The Savary-Miller scaling graduated table was the most normally applied while the Los Angeles ( LA ) graduated table is the most frequently used rating graduated table for reflux esophagitis. Table 2.4 and Table 2.5 are the categorizations of the scaling strategy for the Savary-Miller scaling graduated table and the LA graduated table:

Table 2.4: The Savary – Miller categorization of reflux esophagitis




Single eroding above gastro-esophageal mucosal junction


Multiple, non- circumferential erodings above gastro-esophageal mucosal junction


Circumferential erodings above mucosal junction


Chronic alteration with esophageal ulceration and associated stenosis


Barett ‘s gorge with histologically confirmed enteric distinction with columnar epithelial tissue

Table 2.5: The LA categorization of reflux esophagitis




One or more mucosal break non longer than 5 millimeter, that does non widen between the tops of two mucosal creases


One or more mucosal interruption more than 5 millimeters long that does non widen between the tops of two mucosal creases


One or more mucosal interruption that is continuousbetween the tops of two or more mucosal creases but involves less than 75 % of the perimeter


One or more mucosal break which involves at least 75 % of the perimeter

( Beginning: ? ? ? ? ? ? ? ? Lundell et al. , 1999 )

2.4 Clinical Practice Guidelines

As stated in the 2004 Asia-Pacific Consensus on the direction of GERD, lifestyle alterations are normally used as first line of therapy in patients showing with GERD-related symptoms. They include weight loss, smoking surcease, turning away of postprandial recumbency for a period of at least 3 H, lift of the caput of the bed, turning away of tightfitting garments, and turning away of big heavy repasts every bit good as nutrient and imbibe that exacerbate GERD symptoms ( e.g. spicy nutrients, fatty repasts, Mentha piperita, cocoa, onions, citrous fruit juices, and carbonated drinks ) ( DeVault & A ; Castell, 2005 )

H2RAs and alkalizers are normally used for episodic pyrosis, chiefly for postprandial pyrosis. The oncoming of action of alkalizers on esophageal acerb concentration is 30 min after dosing and suppression persists for 1 H, an outlook that the PPI are improbable to provide.65? ? ? ? ? However, surveies reported that meaningful pyrosis alleviation can already be achieved 19 min after consumption.66 In contrast, H2RAs have been shown to supply symptom alleviation within 30 min of dosing that can last up to 12 h.67 There is some grounds to propose that coincident ingestion of both an H2RA and an alkalizer provides better control of esophageal acerb exposure and pyrosis symptoms, when compared to the clinical consequence of each one of theseproducts entirely ( Robinson et al. , 2001 ) . There are indicants of plagiarism – cut and paste, right?

PPIs are the most efficacious medical intercession for GERD. Surveies have shown repeatedly and systematically that PPIs are superior to histamine 2 receptor adversaries ( H2RAs ) in mending the esophageal mucous membrane and alleviating GERD-related symptoms of patients with ERD ( Caro et al. , 2001 ) . In a meta-analysis, the writers demonstrated that after 12 hebdomads of intervention, mending rates were 83.6 % with PPIs, 51.9 % with H2RAs, 39.2 % with Carafate, and 28.2 % with placebo ( Chiba et al. , 1997 ) . In add-on, intervention with PPIs resulted in mending rates of esophageal redness and alleviation of pyrosis symptoms that were two-fold higher than what was observed in patients having H2RAs. Similarly, PPIs demonstrate high quality in alleviating pyrosis symptoms in patients with NERD when compared to H2RAs ( Richter et al. , 2000 ) .

Harmonizing to NICE counsel for indigestion ( 2004 ) , patients who are present with typical GERD symptoms should be started on full dosage PPI for 4 – 8 hebdomads. If patients have terrible esophagitis and stay diagnostic, double-dose PPI for a farther 4 hebdomads may increase the mending rate. PPIs appear more effectual than H2RAs in endoscopy-negative reflux disease. For repeating symptoms, a PPI at the lowest dosage possible should be given to command symptoms, with a minimal figure of repetition prescriptions. PPIs are more effectual than H2RAs at keeping against backsliding of esophagitis in tests of 6-12 months continuance ( NICE, 2004 ) .

American Gastroenterology Association ( AGA ) drew the same guidelines and it was adopted by the National Guidelines Clearinghouse on GERD that lifestyle alterations should be recommended throughout the intervention of GERD. This is followed by pharmacological intervention such as H2-receptor adversaries ( H2RAs ) , proton pump inhibitors ( PPIs ) , and prokinetics. For non-erosive reflux disease ( NERD ) , Step-up ( H2RAs followed by a PPI if no betterment ) and step-down ( PPI followed by the lowest dosage of acerb suppression ) therapy are every bit effectual for both acute intervention and care. On-demand ( patient-directed ) therapy is the most cost-efficient scheme. For erosive esophagitis, initial PPI therapy is the intervention of pick for ague and care therapy for patients with documented erosive esophagitis. Antireflux surgery is an alternate mode in the intervention of GERD in patients who have documented chronic reflux with recalcitrant symptoms ( DeVault & A ; Castell, 2005 ) .

2.5 Pharmacology of PPIs

All PPIs are substituted benzimidazoles that suppress the concluding measure in stomachic acid secernment by adhering to the proton pump ( H+/K+-ATPase enzyme system ) on the stomachic parietal cell. The proton pump inhibitors are given in an inactive signifier. The inactive signifier is neutrally charged ( lipotropic ) and readily crosses cell membranes into intracellular compartments ( like the parietal cell canaliculus ) that have acidic environments. In an acid environment, the inactive drug is protonated and rearranges into its active signifier. The active signifier will covalently and irreversibly adhere to the stomachic proton pump, deactivating it. Minor differences exist among PPIs with regard to the mechanism of action within the parietal cell ( Vanderhoff & A ; Tahboub, 2002 ) . Rabeprazole forms a partly reversible bond with the proton pump ( Vanderhoff & A ; Tahboub, 2002 ) . Pantoprazole preferentially binds avidly to an extra acid suppressing cycteine residue located deep within the membrane which greatly impairs the reversibility of bindings and prolongs continuance of action ( Welage & A ; Berardi, 2000 ) . Once suppression occurs, recovery can merely happen with regeneration or resynthesis of new ATPase. Recovery is hence by and large a comparatively slow procedure compared with the initial inactivation ( Fock et al. , 2008 ) .

2.6 Pharmacokineticss of PPIs

Table 2.7 showed the pharmacokinetics of the five PPI drugs. The absolute bioavailability ranges from 35 % for a individual dosage of Prilosec to 90 % with repeat disposal of esomeprazole. Unlike other PPIs, the bioavailability of rabeprazole remains unchanged with perennial dosing. On the whole, the clip to make the extremum plasma concentration ( tmax ) is about 2 hours. After soaking up into the circulation, PPIs are taken up preferentially by stomachic parietal cells, particularly when they are actively releasing acid. Once suppression occurs, recovery can merely happen with regeneration or resynthesis of new ATPase. These mechanisms suggest that despite the short riddance half-lives, the biological consequence persists for much longer ( Fock et al. , 2008 ) .

All PPIs are extensively protein edge and undergo hepatic metamorphosis via the cytochrome ( CYP ) P450 tracts and the isoforms CYP2C19 and CYP3A4. Esomeprazole is the S-isomer of Prilosec, which is a racemic mixture of two optical isomers, the R- and S-isomers. However, esomeprazole and the omeprazole differ in the ratios in which they are metabolised by CYP2C19 and CYP3A4. Esomeprazole is metabolised to a greater extent by CYP3A4 than omeprazole and to a lesser extent by CYP2C19 ( Abelo et al. , 2000 ) . CYP2C19 genotypes are classified into the three groups, i.e. extended metabolisers ( EMs ) , intermediate metabolisers ( IMs ) and hapless metabolisers ( PMs ) ( Lim et al. , 2005 ) . The metamorphosis of rabeprazole does non look to be significantly affected by CYP2C19 where in one peculiar survey on rabeprazole showed similar healing rates at 4 and 8 hebdomads were obtained in EMs, IMs and PMs ( Ariizumi et al. , 2004 ) , whereas for Prilosec, Prevacid and pantoprazole, a pronounced difference in metamorphosis exists between EMs and PMs ( Ishizaki & A ; Horai, 1999 ) . At 4 hebdomads, the healing rates were 57.1 % , 69.2 % and 72.7 % in EMs, IMs and PMs, severally, while the healing rates at 8 hebdomads were 77.4 % , 95.0 % and 100 % , severally ( Kawamura et al. , 2003 ) . These differences in polymorphisms affect the metabolic and pharmacokinetic profiles of PPIs and may act upon the curative effectivity. Esomeprazole has a lower entire intrinsic clearance than Prilosec, and its first-pass metamorphosis is decreased compared with Prilosec. The advantageous metamorphosis of esomeprazole consequences in higher country under the plasma concentration-time curve ( AUC ) values than those for Prilosec at the same dosage, and hence may accomplish better acid suppression than Prilosec in clinical pattern ( Fock et al. , 2008 ) .

Rabeprazole, Prevacid and pantoprazole have similar bioavailability on yearss 1 and 5. The bioavailability of omeprazole additions 1.5 to 2 crease at twenty-four hours 5, while that of esomeprazole additions 3 crease at twenty-four hours 5 ( Hellstrom & A ; Vitols, 2004 ) .

The presently available PPIs have short riddance half-lives runing from 1 to 1.5 hours. A PPI with a longer elimination half life may bring forth more drawn-out encirclement of proton pumps with the potency for greater acid suppression and, therefore, a greater clinical consequence, peculiarly for patients with important postprandial eventide and/or nocturnal symptoms ( Fock et Al, 2008 )

Table 2.6: Pharmacokineticss of PPIs








90 %

80 % -85 %

30 % -40 %

77 %

52 %

Time to top out plasma concentration

1.5 hours

1.7 hours

0.5-3.5 hours

2.5 hours

2-5 hours

Half-life ( plasma )

1.2-1.5 hours

1.5 hours

0.5-1 hr

1 hr

1-2 hours

Major cytochrome P450 tract








Protein binding

97 %

97 %

95 %

98 %

96.3 %

2.7 Clinical Efficacy of PPI drugs

All dual blind randomised surveies that were published comparing two or more PPIs or doses for the intervention of acute gastroesophageal disease ( GERD ) were obtained. The prospective ratings of mensurable clinical efficaciousness such as healing of esophagitis or symptoms declaration were summarized in Appendix A.

In one survey comparing esomeprazole 40 milligram, esomeprazole 20 milligram and omeprazole 20 milligram one time day-to-day, pH & gt ; 4 was maintained for 16.8 hours, 12.7 hours and 10.5 hours severally ( Lind et al. , 2000 ) . In another survey affecting 2425 patients with erosive esophagitis, esomeprazole 40 milligram and omeprazole 20mg were compared at 4 and 8 hebdomads. At 4 hebdomads, 93.7 % on those on esomeprazole and 84.3 % of those on Prilosecs were healed ( Richter et al. , 2001 ) . One survey with 1960 patients with erosive esophagitis, it was found that esomeprazole 40 milligram, esomeprazole 20 milligram and omeprazole 20 milligrams have mending rates of 94.1 % , 89.9 % and 86.9 % severally ( Kahrilas et al. , 2000 ) . These surveies were frequently cited as grounds of the high quality of esomeprazole in esophageal healing, but it should be noted that the dosage is non comparable. A meta-analysis concluded that esomeprazole healed erosive esophagitis at important higher rates than Prilosec ( Edward et al. , 2001 ) . However, all the surveies were funded by AstraZeneca and two out of the three writers are employed by AstraZeneca.

In the lone survey that use comparable doses of esomepazole and Prilosec at 40 milligram severally, those taking esomeprazole maintained a stomachic pH & gt ; 4 for a mean of 16.4 hours while those taking omeprazole maintained for 14.9 hours. However, its little sample size of 114 patients limits its cogency ( Rohss et al. , 2002 ) .

In another survey, esomeprazole 40 milligram were more effectual than lansoprazole 30 milligram for healing of esophagitis ( Castell et al. , 2002 ) . In a randomised dual blind survey, more patients were healed following 8 hebdomads of intervention with esomeprazole 40 milligrams compared to pantoprazole 40 milligram ( Labenz et al. , 2005 ) . All the above surveies showed a superior efficaciousness towards esomeprazole 40 milligram because all surveies used higher dosage of esomeprazole for comparing, where the criterion dosage of esomeprazole that should be used was esomeprazole 20 mg. All the surveies were non of true comparings.

When comparing lansoprazole 30A milligram with omeprazole 20A milligram, there is no important difference in mending rates at 4A hebdomads ( RR 1.02 ; 95 % CI: 0.97, 1.08 ) and 8A hebdomads ( RR 1.01 ; 95 % CI: 0.97, 1.06 ) ( Hatlebakk et al. , 1999 ; Castell et al. , 1996 ; Mee & A ; Rowley,1996 ) . There is no important difference with pantoprazole 40A milligram ( Corinaldesi et al. , 1995 ; Mossner et al. , 1995 ) or rabeprazole 20A milligram when compared with omeprazole 20A milligram ( Dekkers et al. , 1999 ) .

Vakil and Fennerty reviewed 32 surveies and stated that there are deficient informations to set up high quality of any one agent. The meta-analysis concluded that all PPIs have similar authority and the same built-in capacity to suppress acerb secernment.

A Cochrane Collaboration reappraisal concluded that there was no statistically important difference in healing of reflux esophagitis of the different PPI medicines when given in tantamount dose ( Khan et al. , 2007 ) . The American College of Gatroenterology has stated in their pattern guidelines that all Prilosec, pantoprazole, rabeprazole, Prevacid and esomeprazole have been demonstrated to command GERD symptoms and to mend esophagitis when used at prescription doses ( DeVault & A ; Castell, 2005 )


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