I’ve read all threads and the most recent study on successful use of Esomeprazole (Nexium) 60 mg for ulcer treatments. Can someone tell me why the same use of 60mg of Omeprazole is not the same? I understand a horse needs 2.28 grams of omeprazole per day, 2.28 grams is 2,280 milligrams. If I am understanding this correctly that would mean you would need 114 Omeprazole 20mg pills per day… why is the Nexium dose so much less?
Because they are different drugs and esomeprazole is more effective.
Example: this human study:
“Esomeprazole demonstrates significantly greater efficacy than omeprazole.”
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Omeprazole consists of a 1:1 ratio of Esomeprazole plus its non-identical mirror image (AKA, it’s enantiomer). The mirror image, as noted by @Simkie, is less effective. I know that seems like a tiny difference, but it can be very significant, including in biological systems.
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Have there been any studies showing that Nexium is more effective than GastroGuard in equines? I sure would love a less expensive option.
There are a few papers about esomeprazole in equines linked in the Nexium thread. It’s linked on my usercard (click my name to show it.)
Afaik, there’s been no head to head comparison of Gastrogard & Nexium though, no.
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There are studies showing what doses of eso raise pH to the level that omeprazole does, for X amount of time. That SHOULD, theoretically, show that it can be just as effective, since the entire principle is about raising pH for X hours every day for X days.
The 60/80mg dosing of eso really only raises pH for about 6 hours.
You need 0.5-2.0mg/kg to get pH raised for 24 hours (though actually I think the study showed just 23 hours.
Still, a 14 capsule bottle of eso, which is(roughly, it’s a little more) the .5mg/kg dose for a 500kg horse, is still way cheaper than a tube of UG/GG
Where are you getting this?
If you’re using the Pereira et al study, that’s not what it showed. They measured gastric pH for six hours following administration of 40/80 mg esomeprazole, then at 24h. Between 6h and 24h, the gastric pH returned to baseline. That study doesn’t show when that happened. Saying that a low dose only raises the gastric pH for 6h based on the Pereira paper is incorrect. We don’t know when the pH begins to drop following a 40/60/80 mg dose, only that it was back down to baseline at 24h.
Given that we have quite a lot of anecdotal report that a course of Nexium at a low dose was effective, it seems quite plausible that it’s maintaining the pH at >4 for “long enough” (the bulk of a 24h period) and reasonable to still consider using a low dose in uncomplicated and straightforward cases, especially where $$ are a concern. There may also be less risk to the hind gut with a lower dose.
If there is another study that has hourly testing of gastric pH up to 24h following a 40/60/80 mg dose of esomeprazole, I would love to see it.
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You’re right, I mis-remembered the 6h detail.
For sure 40/60/80mg works wonders for a lot of horses. It doesn’t work for all. For at least some of these, omeprazole did the trick. Is that because the dose isn’t large enough? Because the pH wasn’t high enough for long enough? No idea because most that I’ve seen haven’t scoped, and we don’t actually know how many hours past 5, the eso raises it enough
For sure, omeprazole works wonders for a lot of horses. It doesn’t work for all. There are lots of reasons why, including not having scoped and not using the right medication for the ulcers present (or not ALL of the right meds)
Uh, we do have some data past 5h. Because Pereira et al measured to 6h. And at that time, gastric pH was >5, which is a 10 fold increase over pH 4 (since pH is a logarithmic scale) and was declining slowly.
I can’t imagine this is what you mean, but scoping doesn’t change the efficacy of omeprazole. It’s not like it won’t work if you don’t scope and will if you scope. If it’s going to be effective for the horse, it’ll work regardless of if you scope or not. If it’s not going to work, scoping won’t change that.
I don’t disagree at all that more study is necessary in this area to truly KNOW what dose of esomeprazole is appropriate. But I absolutely disagree that
because we don’t know that, either.
And I still very much hold that 60 mg of esomeprazole has produced results in quite a few horses, and is a reasonable thing to try, particularly when money is of concern. If it doesn’t work, scope the horse and come up with a plan with the vet, either with a higher dose of esomeprazole, switching to omeprazole, or switching/adding other meds entirely.
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typo, sorry.
No, that isn’t what I meant. If you don’t scope, don’t know you have glandular ulcers, and are only using omeprazole, you may not have much if any improvement. So those who say “omeprazole doesn’t work” without any data to support why, are just shooting blindly.
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Yes, but that really has nothing to do with the act of scoping itself, just that the wrong drug is being used.
I certainly agree that failure to respond to PPI can be multifactorial–wrong dose, wrong duration, wrong med, wrong diagnosis. Scoping gives you more info that can aid targeting therapy appropriately.
But scoping is expensive for many and often stressful, and there are still an awful lot of very straightforward ulcer cases out there that can be treated without that expense & stress–and it’s not unreasonable to try that first for many owners.
A low dose of Nexium can be an reasonable tool, since we do have data that shows it’s capable of raising the gastric pH, anecdotal data of efficacy, and actual research that is, at the very least, suggestive that it does the job.
Yes, I understand, but the fact is, someone can’t just say “esomeprazole/omeprazole” didn’t work, blaming the drug, when there is no scoping to say it should have or shouldn’t have based on the kind (and severity) of ulcers.
People have said the low dose eso didn’t work, but UG/GG did. Is that because the eso just didn’t raise pH long enough to get the job done? Absolutely no idea. It IS a possibility, and we do know that the other doses keep pH up for much longer.
There are also people who use UG/GG for 2 weeks, or who use a prevention dose for 30 days, and proclaim the horse healed. Without scoping, that isn’t proof that you don’t need 30 days, or a full treatment dose - it may simply mean ulcers were low in number and very mild.
There are certainly enough situations where low dose eso has done the job that it warrants a trial anyway. I just don’t want people blaming 60mg of eso for lack of improvement, when they might simply need the higher dose.
Yep, totally agree with all of that. Lots of people make assumptions about the efficacy of all of these meds without scoping, and those assumptions can be wrong.
My point here is that while we do have some data about esomeprazole, we don’t know what the lowest effective dose is. We DON’T know that you must use at least 0.5 mg/kg. We DO know what the first 6 hours following a 40/80 mg dose looks like.
There are still a lot of unanswered questions. Better to state what we do know than make inaccurate statements that are not supported by the existing literature–like the pH drops under 4 at the 6 hour mark after 40/80 mg of esomeprazole (that’s not true) or that at least 0.5 mg/kg is required to raise the gastric pH above 4 for 24 hours (we don’t know that) or that we have no data past 5h with a 40/80 mg dose (we have up to 6h, where the pH was >5 and dropping slowly.)
Owners who want as much info as possible and the best shot at addressing their horses symptoms quickly and completely should scope and treat with the agents that have the most evidence–probably gastrogard for straightforward ulcer presentations, or whatever combo is more appropriate for the more complex cases.
But scoping & treating with gastrogard is a reach for many. That surety comes with a cost. Many cases of gastric ulcers are not particularly complicated. And starting with a low dose of esomeprazole is both economical and reasonable given what we do know. Will it work for everyone? Nope. But it sure can be a place to start, and sure seems to work for quite a lot. Treating with a higher dose of esomeprazole is certainly an option for owners who want to arbitrage and come in somewhere between the expense of scope/gastrogard & a low esomeprazole dose–but saying that’s necessary just isn’t something we know.
I always prefer to treat with as little as necessary to produce the result I need. As someone who has found 60 mg Nexium effective at not only treating ulcer symptoms that I’ve seen in my horses, but also effective as a preventative in the face of stressful events, I see zero reason to more than quadruple that dose given that we have no literature showing that it’s necessary. Sure, at some point, it might not work, and that’s when the next step should be further investigation.
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