From a pharmacokinetics perspective, you’d probably have a more consistent pharmacodynamic (i.e., pH-adjusting) effect from twice daily dosing. When I’ve done this, I’ve done twice a day dosing like you to try and maintain homeostasis. (disclaimer: I’m not a pharmacokineticist or pharmacist, but I have authored a fair number of published PK and PK/PD papers about drugs seeking FDA approval.)
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No, we don’t know this. Because the Sykes paper you think says this doesn’t. Have you read the full text?
What Sykes et al 2017 actually reported was:
“The reported %tpH>4 of 73.2 (± 29.7) % for 0.5279 mg/kg in the HG/LF diet and 81.4 (± 22.0) % for 2.0 mg/kg in the HAY diet supports further investigation of 0.5 mg/kg and 2.0 mg/kg as therapeutic doses of esomeprazole for the treatment of EGUS in horses consuming HG/LF and HAY diets, respectively”
0.5 mg/kg and a high grain/low fiber diet yielded a pH of greater than 4 for an average of 73.2% of the study period (plus minus nearly 30%)
2.0 mg/kg and a hay diet yielded a pH of greater than 4 for an average of 81.4% of the study period (plus minus 22%.)
Neither dose consistently kept the pH greater than 4 over the study period.
This is still a success because maintaining a pH of greater than 4 over a 24 hour period isn’t necessary according to Sykes.
Maintaining a pH over 4 might not even be necessary; ph > 3 may be enough. Again per Sykes. I included this from the 2017 Sykes et al paper earlier, but here it is again.
"In humans, good healing rates for gastroesophageal reflux disease, which is analogous to ESGD, are achieved when the %tpH>4 exceeds 66% [9] while %tpH>3 is used as a benchmark for glandular healing in other species with a %tpH>3 of greater than 66% required in humans for healing of glandular disease [9]. Unfortunately, due to limitations in the software of the reporting program, determination of %tpH>3 was not possible. Regardless it has been proposed that %tpH>4 may be a more conservative benchmark until species-specific breakpoints for healing are determined [10].”
And, just musing at this point, but having a period of normal pH in the stomach may be protective against delayed gastric emptying syndrome, because we do know that the stomach empties dependent on pH of the contents. Maintaining a pH of > 4 for a 24 hour period or multiple 24 hour periods may not be a good idea, anyway.
Just an update in case anyone else has the same issue - the six pills 2x a day seems to have done the trick for my horse. At least, he isn’t touchy and has had an improvement in general attitude.
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So, there is a lot of back and forth and confusion and such can someone repeat the dosages?
6 pills am 6 pills pm for 30 days?
There is no one answer. It’s your own interpretation of the literature that’s out there.
I am still very comfortable with 60 mg (3 capsules) once daily. I would not personally use 6 twice daily.
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3 once a day for how many days?
A month. Then taper.
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This new research article showed up on my Facebook tonight. https://equimanagement.com/research-medical/comparison-of-oral-esomeprazole-and-oral-omeprazole-for-treating-esgd/?lid=wte0i07wwlut&fbclid=IwAR0nco_5SWcMsHsUSJ81IRUTn8GyqkDMwP9wFmpb1SrtNumF6Ob-u2ND5Lg_aem_AdqUE_EpsByChLNCdyJ0_87pb7gMk3sgd3UYyQQwOtq4-U3PJ4rO9OnnPqM0iVbpPAI&mibextid=S66gvF
Huh! That’s interesting. Thanks for sharing!
I’m not actually surprised, since eso is a cousin to o.
Note that a higher dose of esomeprazole was used compared to the other studies I’ve seen, at 4mg/kg, same strength as omeprazole, and double the highest dose that I’ve seen so far.
I sure wish they’d done a trial at a 2mg/kg dose as well.
At 4mg/kg, that’s 100 of the OTC pills for an 1100lb (500kg) horse. Using Walmart’s price of $15 for a 42 pack, that comes to $35.70/day. Same-ish as Ulcer/Gastrogard
I sure hope someone will do the same study at 2mg/kg.
I also would like to see a study of that 4mg/kg vs Omeprazole (at 4mg/kg) + sucralfate, and vs omeprazole + misoprostol, because if it’s at least the same effectiveness as UG/GG + either of those 2, then this would be a cheaper alternative if it can be used on its own, not to mention saving a lot of heartache on timing those medications
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I just got 42 pill packs on sale for $5.78 at Amazon Fresh
Amazon Basic Care Esomeprazole Magnesium Delayed-Release Mini Capsules, 20 mg, Acid Reducer, 24 Hour Heartburn Medicine, 42 Count https://a.co/d/735lwEj
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Must’ve been a flash sale - those are $20 now 
. They do go on sale occasionally though, if you spend enough time scrolling Amazon for deals.
What??? $15 for a 42 pack? Even at $20 for a pack, that"s dirt cheap to what pay in my area. $16 (plus 13% tax…) for a pack of 14 capsules.
I always get them at Walmart. They have 42 pills (3 pack) for $14.97
I’m assuming you’re in the US? I’m in Canada, wish ours was that cheap 
LOL yes, US Walmart!
Maybe I’m just dense, but I find the design and purpose of this study perplexing.
Omeprazole and esomprazole aren’t “cousins.” They’re the same molecule. Omeprazole is a mixture of s-omeprazole and r-omeprazole. They’re mirror image molecules, like how your two hands are the same shape, but mirror images of each other. s-omeprazole has proven to be more effective than r-omeprazole, so it’s been branded “esomeprazole” (the people who name drugs are not very creative lol) and sold as it’s own drug.
This study, where the treatment arms are 4 mg/kg of omeprazole or 4 mg/kg of esomprazole, is curious. The omeprazole arm is receiving 2 mg/kg of s-omeprazole and 2 mg/kg of r-omeprazole. The esomeprazole arm is receiving 4 mg/kg of s-omeprazole. The esomeprazole arm is receiving twice as much s-omeprazole as the omeprazole arm. Other studies that have compared omeprazole to esomerazole straight up have taken this into account, and dose omeprazole at 4 mg/kg and esomeprazole at 2 mg/kg–essentially comparing omeprazole (the mixture of s- and r-) to the same dose of s- alone with esomeprazole. Asking the question…is the r- form necessary? Can we just give the more active s- form at the same dose? And the answer seems to be yes.
But in this study, they’re giving 2x the more active s- form in the esomeprazole arm. The esomerazole arm saw better results across the board:
In equine squamous gastric disease (these are the “usual” gastric ulcers) 85% of the horses treated with esomeprazole were healed after the treatment period, as opposed to 59% of those treated with omeprazole.
In equine glandular gastric disease (these horses also had squamous ulcers) 55% of the esomeprazole treated horses were considered “healed” with lesions graded at one or less, as opposed to 25% of the omeprazole group.
But because of the way this study was dosed, it’s impossible to say if that’s because esomeprazole is actually better at healing, or if it’s just the fact that those horses received twice the more active drug component. Would doubling the omeprazole dose have the same effect? Very likely.
What I found MOST interesting about this one is the low healing rates on omeprazole. This is supposed to be our gold standard, treat for 30 days and your horse is (usually) cured! But less than 60% of horses in the squamous group treated with omeprazole were. So are we expecting too much when we rescope and see ulcers after 30 days?
The authors here say this:
“In this and the previous study in which lower rates of healing were reported, healing was classified as grade 0, whilst in other studies, improvement to grade ≤1 was used for healing.”
Which was news to me. Do we need to reset our expectations on even what omeprazole can do?
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I also found it a bit odd. My interpretation is that they have a new product (the esomeprazole buffered paste) that they want to market so they wanted to do as direct a comparison to Gastrogard as possible. But then they didn’t actually use GG since it’s apparently not licensed in Australia. So I don’t really know.
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Australia has their own version of UG/GG, and that is the product they used in another study some years ago showing how lower doses also healed ulcers, which got SO MANY people here in the US claiming they too could use 1/4 and 1/2 tubes to treat. But it’s not the same product.
The paper says:
“The oral omeprazole product used was selected because it is similar to GastroGard™ (Boehringer Ingelheim), the oral omeprazole product that is the most widely studied in the literature and is the most widely used globally. GastroGard™ is not registered in the country where the study was performed, hence the use of a similar alternative.”
But hard to tell what “similar to GG” really means.
