From Mr S. T. Garner, MRPharmS
SIR,—I write to respond to the letter from Dr Maisey (PJ, October 30, p710). I feel that the emphasis that Dr Maisey places on cost when choosing a proton pump inhibitor is worthy of debate.
As a former hospital chief pharmacist, I have made a particular study of PPIs and have also acted as an independent consultant to Astra Zeneca on occasion. Like Dr Maisey, I do recognise the importance of cost-effective prescribing in the management of gastro-oesophageal reflux disease (GORD). However, there are a number of factors that need to be taken into account when deciding on a choice of treatment.
GORD is a highly prevalent and potentially serious condition. Not only does it considerably impair quality of life, it is also associated with significant complications, such as oesophageal ulcer, stricture, and Barrett's oesophagus.
Clinical symptoms of GORD do not correlate well with severity of disease, such that around half of patients with apparently mild symptoms may in fact have an endoscopic lesion of oesophagitis.1 This demonstrates that, without the benefit of endoscopy, the goal of management should be healing and not simply symptom resolution alone. Therefore, the reliability of the healing afforded by the treatment should be paramount.
Dr Maisey advocates the use of lansoprazole 15mg in the step-down regimen for the management of GORD. It should be noted that, while both lansoprazole 30mg and omeprazole 20mg are licensed for healing in patients with reflux oesophagitis, lansoprazole 15mg is not. The cost differential between the two PPIs is minimal when comparable doses are used.
In terms of maintenance of healing, I agree with Dr Maisey that we should use the lowest effective dose of PPI. In this regard, omeprazole 20mg is superior to lansoprazole 15mg in the prevention of relapse of reflux oesophagitis, with 90 per cent of patients treated with omeprazole 20mg (n=302) remaining in endoscopic remission at 12 months compared with only 76 per cent of patients remaining in remission treated with lansoprazole 15mg (n=295) (p<0.01).2 Without knowing, on the basis of clinical symptoms alone, whether patients are truly in endoscopic remission, the choice and dose of PPI should be that which provides the most reliable healing. In terms of cost-effective prescribing, with the recent price adjustments, both 10mg omeprazole and 15mg lansoprazole (the licensed doses in the long-term management of GORD) are comparable to ranitidine.
Finally, the study protocol used in the trial by Baldi et al,3 which was cited by Dr Maisey to say that lansoprazole 15mg is more effective than omeprazole 10mg, did not include omeprazole 10mg.
Stephen T. Garner
Bottesford, Nottingham