Omeprazole, sold under the brand names Prilosec and Losec among others, is a medication used in the treatment of gastroesophageal reflux disease (GERD), peptic ulcer disease, and Zollinger–Ellison syndrome. It is also used to prevent upper gastrointestinal bleeding in people who are at high risk. Omeprazole is a proton-pump inhibitor (PPI) and its effectiveness is similar to that of other PPIs. It can be taken by mouth or by injection into a vein. It is also available in the fixed-dose combination medication omeprazole/sodium bicarbonate as Zegerid and as Konvomep. Common side effects include nausea, vomiting, headaches, abdominal pain, and increased intestinal gas. Serious side effects may include Clostridioides difficile colitis, an increased risk of pneumonia, an increased risk of bone fractures, and the potential of masking stomach cancer. Whether it is safe for use in pregnancy is unclear. It works by blocking the release of stomach acid. Omeprazole was patented in 1978 and approved for medical use in 1988. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. In 2023, it was the tenth most commonly prescribed medication in the United States, with more than 45 million prescriptions. It is also available without a prescription in the United States.
Medical uses
Omeprazole can be used in the treatment of gastroesophageal reflux disease (GERD), heartburn, peptic ulcers, erosive esophagitis, Zollinger–Ellison syndrome, and eosinophilic esophagitis.
Peptic ulcers Peptic ulcers may be treated with omeprazole. Infection with Helicobacter pylori can be treated by taking omeprazole, amoxicillin, and clarithromycin together for 7–14 days. Amoxicillin may be replaced with metronidazole in patients who are allergic to penicillin.
Adverse effects Adverse effects occurring in at least 1% of people include:
Central nervous system: headache (7%), dizziness (2%) Respiratory: upper respiratory tract infection (2%), cough (1%) Gastrointestinal: abdominal pain (5%), diarrhea (4%), nausea (4%), vomiting (3%), flatulence (3%), acid regurgitation (2%), constipation (2%) Neuromuscular and skeletal: back pain (1%), weakness (1%) Dermatologic: rash (2%) Other concerns related to adverse effects are:
Recurrence of Clostridioides difficile associated diarrhea Osteoporosis-related fractures Hypomagnesemia Concern has been expressed regarding vitamin B12 and iron malabsorption, but effects seem to be insignificant, especially when supplement therapy is provided. Since their introduction, proton-pump inhibitors (PPIs, especially omeprazole) have also been associated with several cases of acute interstitial nephritis, an inflammation of the kidneys that often occurs as an adverse drug reaction.
Long-term use Long-term use of PPIs is strongly associated with the development of benign polyps from fundic glands (which is distinct from fundic gland polyposis); these polyps do not cause cancer and resolve when PPIs are discontinued. No association is seen between PPI use and cancer, but use of PPIs may mask gastric cancers or other serious gastric problems. There is a possible association between long-term use and dementia which requires further study to confirm. An article published in 2013 claims that the long-term use of PPIs is associated with decreased calcium absorption (causing increased risk of osteoporosis and fractures), decreased magnesium absorption (causing electrolyte disturbances), and increased risk of certain infections, such as C. difficile and community-acquired pneumonia. The authors hypothesize that this is due to decreased stomach acid production.
Pregnancy and breastfeeding The safety of using omeprazole has not been established in pregnant or breastfeeding women. Epidemiological data do not show an increased risk of major birth defects after maternal use of omeprazole during pregnancy.
Interactions
Important drug interactions are rare. However, the most significant major drug interaction concern is the decreased activation of clopidogrel when taken together with omeprazole. Although still controversial, this may increase the risk of stroke or heart attack in people taking clopidogrel to prevent these events. This interaction is possible because omeprazole is an inhibitor of the enzymes CYP2C19 and CYP3A4. Clopidogrel is an inactive prodrug that partially depends on CYP2C19 for conversion to its active form. Inhibition of CYP2C19 may block the activation of clopidogrel, which could reduce its effects. Almost all benzodiazepines are metabolised by the CYP3A4 and CYP2D6 pathways, and inhibition of these enzymes results in a higher area under the curve (i.e., the total effect over time of a given dose). Other examples of drugs dependent on CYP3A4 for their metabolism are escitalopram, warfarin, oxycodone, tramadol, and oxymorphone. The concentrations of these drugs may increase if they are used concomitantly with omeprazole. Omeprazole is also a competitive inhibitor of p-glycoprotein, as are other PPIs. Drugs that depend on an acidic stomach environment (such as ketoconazole or atazanavir) may be poorly absorbed, whereas acid-labile antibiotics (such as erythromycin which is a very strong CYP3A4 inhibitor) may be absorbed to a greater extent than normal due to the more alkaline environment of the stomach. St. John's wort (Hypericum perforatum) and Ginkgo biloba significantly reduce plasma concentrations of omeprazole through induction of CYP3A4 and CYP2C19.
Pharmacology Omeprazole irreversibly blocks the enzyme system on parietal cells that is needed for the secretion of gastric acid. It is a specific H+/K+ATPase inhibitor. This is the enzyme needed for the final step in the secretion of gastric acid.
Pharmacokinetics The absorption of omeprazole takes place in the small intestine and is usually completed within three to six hours. The systemic bioavailability of omeprazole after repeated doses is about 60%. Omeprazole has a volume of distribution of 0.4 L/kg. It has high plasma protein binding of 95%. Omeprazole is completely metabolized by the cytochrome P450 system, mainly in the liver, by CYP2C19 and CYP3A4 isoenzymes. Identified metabolites are the sulfone, the sulfide, and hydroxy-omeprazole. About 77% of an orally given dose is excreted as metabolites in the urine, and the remainder is found in the feces, primarily originating from bile secretion. Omeprazole has a half life of 0.5 to 1 hour.
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