India · Paediatric mg/kg & Adult · GERD · Peptic Ulcer · H. pylori · Stress Ulcer · Omez · Pan · Pantocid
PPIs only inhibit actively secreting proton pumps. Taking with or after food significantly reduces efficacy. Counsel every patient on timing.
⚠️ Long-term PPIs: hypomagnesaemia, C. diff risk, B12 deficiency
⚠️ Omeprazole + clopidogrel: reduced antiplatelet effect — use pantoprazole
⚠️ Screen for H. pylori before long-term PPI use
⚠️ Avoid indefinite PPI use without clear indication
| Indication | Adult dose | Paeds dose | Duration |
|---|---|---|---|
| GERD / maintenance | Omeprazole 20mg OD or Pantoprazole 40mg OD | 1 mg/kg/day OD (max 20mg) | 4–8 weeks; ongoing if needed |
| Erosive GERD / oesophagitis | Omeprazole 40mg OD or Pantoprazole 40mg OD | 1–2 mg/kg OD (max 40mg) | 8 weeks |
| Peptic ulcer — healing | Omeprazole 20–40mg OD | 1 mg/kg OD (max 40mg) | 4–8 weeks |
| H. pylori eradication | Omeprazole 20mg BD (with 2 antibiotics) | 1 mg/kg BD (max 20mg BD) | 7–14 days |
| NSAID ulcer prevention | Omeprazole 20mg OD or Pantoprazole 40mg OD | — | Duration of NSAID use |
| Stress ulcer prophylaxis IV | Pantoprazole 40mg IV OD–BD | 0.5–1 mg/kg IV OD (max 40mg) | ICU stay |
| Upper GI bleed IV | Pantoprazole 80mg IV bolus then 8mg/hr × 72h | Specialist only | 72 hours post-endoscopy |
| Zollinger-Ellison | Omeprazole 60mg OD (titrate up) | Specialist directed | Ongoing |
Proton pump inhibitors (PPIs) are the most widely prescribed acid suppression drugs in India, with omeprazole and pantoprazole accounting for the vast majority of use. They irreversibly inhibit the gastric H+/K+-ATPase proton pump, producing profound and sustained acid suppression — significantly more effective than H2-receptor antagonists like famotidine for healing peptic ulcers and oesophagitis. However, overprescription of PPIs is a major problem in Indian clinical practice — they are often started without a clear indication and continued indefinitely without review.
The most clinically important difference between omeprazole and pantoprazole is their cytochrome P450 interaction profile. Omeprazole is a potent CYP2C19 inhibitor, which reduces the conversion of clopidogrel to its active metabolite — potentially increasing cardiovascular events in patients on dual antiplatelet therapy. Pantoprazole has minimal CYP2C19 inhibition and is strongly preferred in any patient on clopidogrel (post-ACS, post-stenting). This is particularly important in Indian cardiology practice where clopidogrel + aspirin is one of the most common drug combinations. For all other indications, both drugs have equivalent efficacy.
India has one of the highest H. pylori prevalence rates in the world (estimated 40–60% of adults in urban areas, higher in rural communities). Standard triple therapy: omeprazole 20 mg BD + amoxicillin 1g BD + clarithromycin 500 mg BD for 14 days (preferred) or 7 days. Clarithromycin resistance is increasing in India — where available, test-and-treat with culture and sensitivity is preferred. Quadruple therapy (bismuth + PPI + metronidazole + tetracycline) is used for clarithromycin-resistant or second-line eradication. The PPI must be given BD (twice daily) for H. pylori eradication — once-daily dosing is insufficient.
For children aged 1 year and above: omeprazole 1 mg/kg/day as a single morning dose before breakfast, maximum 20 mg once daily for standard GERD. For erosive oesophagitis or resistant GERD: 1–2 mg/kg/day, maximum 40 mg. The 10 mg Omez capsule is available in India and can be opened and mixed with a small amount of water or juice for children who cannot swallow capsules — the pellets should not be chewed. Lansoprazole is available as ODT (orally disintegrating tablet) which is more practical for children. PPIs are not recommended for infants under 1 year except under specialist supervision — evidence does not support PPI use for infant reflux.
For variceal and non-variceal upper GI bleeding post-endoscopy: pantoprazole 80 mg IV bolus over 15 minutes, followed by 8 mg/hour continuous infusion for 72 hours. This "high-dose" IV PPI protocol is supported by RCT evidence and is standard practice in Indian endoscopy units. After 72 hours, switch to oral PPI (pantoprazole 40 mg OD or omeprazole 40 mg OD). For stress ulcer prophylaxis in mechanically ventilated ICU patients: pantoprazole 40 mg IV once daily is standard in most Indian ICUs.