Ranitidine vs Omeprazole

After my recent post on Omeprazole’s alternative drugs, I want to stay in the subject of gastro-oesophageal reflux disease (GORD) and its treatment. In this post I will contracts ranitidine vs omeprazole and briefly discuss:

differences between both classes of drugs (mechanism of action)
effectiveness of ranitidine vs omeprazole
their safety (contrast mainly their possible side effects)
concomitant use of both drugs and NICE recommendations to do so

Mechanism of action of ranitidine vs omeprazole

Ranitidine and omeprazole belong to different classes of drugs, both used in the treatment of heartburn/indigestion. Ranitidine is classified as an h2 receptor antagonist, commonly named h2 blockers. Omeprazole belongs to a group of drugs called proton pump inhibitors (PPIs).

The differences of both drugs come from a distinct mechanism of action on stomach acid suppression. Stomach acid is produced in response to activation of one of three receptors located on cells in the lining of the stomach. One type of these receptors (h2 receptors) can be blocked by ranitidine preventing initial production of the acid via this, one route.

PPIs on the other hand block proton pump, which is responsible secretion of the stomach acid in the final part of its production.

Watch the video below to get a more detailed explanation of the mechanism of actions of both drugs.

Ranitidine vs omeprazole: the effectiveness

A number of studies and clinical trials confirmed that PPIs (omeprazole) are more effective in the reduction of acid production than H2-blockers (ranitidine). PPIs are more effective in the reduction of acid production because acid secretion is the last stage of acid production.

Ranitidine vs omeprazole: safety and side effects

Ranitidine is generally well tolerated only with rare and very rare side effects possible. Very rare side effects may include anaphylaxis reaction to ranitidine. To see list of all possible rare side effects read product information leaflet for ranitidine (see an example for ranitidine 75mg P).

Use of omeprazole is associated with a number of common side effects including:

Headaches
Abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting

Long term use of omeprazole (or other PPIs) may increase (BNF,n.d):

Risk of bone fractures (high doses taken mainly by the elderly population)
Risk of gastro-intestinal infections

In 2017 a research paper was published in Gut magazine associating the use of PPIs with increased risk of gastric cancer development. This study looked at patients from Hong Kong who were treated for Helicobacter pylori infection.

H pylori infection can cause recurring episodes of indigestion. Treatment of confirmed H. pylori infection involves taking a short course of 2 different antibiotics with a PPI such as omeprazole (triple therapy).

Although eradication of H. pylori infection reduces the risk of stomach cancer development, the above study found that taking PPIs more than doubled this risk. The average time that PPIs were taken by patients was 3 years after the triple therapy. All patients had a long history of gastritis, which is the inflammation of the stomach lining (BMJ, n.d.). This risk is further increased with the duration of treatment and dose frequency after the triple therapy.

The same study concluded that taking h2 blockers is not associated with an increased risk of stomach cancer development.

Guidelines on the use of ranitidine and omeprazole

The NICE guideline recommends the use of H2-blocker (ranitidine) at night in addition to PPIs (omeprazole) for people with persistent or recurrent symptoms of GORD or confirmed oesophagitis (inflammation of the tube that connects stomach with your mouth). This should be prescribed on short term basis (for example for a 2-week course intermittently).) and when patients experience symptoms at night; subject to clinical judgement by a GP (NICE, 2017). NICE suggests additional use of H2 blockers such as ranitidine is likely to be increasingly ineffective, patients may no benefit from combination treatment and within weeks night-time symptoms may come back (ibid).

Can you take ranitidine and omeprazole together?

Based on clinical judgement, the GP may decide to prescribe both ranitidine and omeprazole. Pharmacologically omeprazole overlaps the mechanism of action of ranitidine. Based on this and as it is suggested by the NICE guidelines addition of ranitidine in the treatment of persistent GORD may bring short benefits, if any.

Other strategies on the management of GORD need to be explored including doubling up the dose or switching from daily to twice daily dosing or switching to a different PPI. Current evidence on the use of these strategies, however, is limited.

To sum up PPIs are more effective in controlling stomach acid production and management of GORD symptoms. PPIs are associated with a number of common side effects; long term use of PPIs may increase the risk of infections and bone fractures. In contrast H2 blockers have a better safety profile, however, they are less effective in reducing stomach acid production.

References:

BMJ (n.d.). Long term use of drugs to curb acid reflux linked to doubling in stomach cancer risk. Available at: https://www.bmj.com/company/newsroom/long-term-use-of-drugs-to-curb-acid-reflux-linked-to-doubling-in-stomach-cancer-risk/ Accessed on 10/06/2019

BNF (n.d.). Omeprazole. Available at: https://bnf.nice.org.uk/drug/omeprazole.html Accessed on 10/06/2019

Cheung KS, Chan EW, Wong AYS, et al Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study Gut 2018;67:28-35. Available at: https://gut.bmj.com/content/67/1/28 Accessed on 10/06/2019

NICE (2017). Dyspepsia – proven GORD. Available at: https://cks.nice.org.uk/dyspepsia-proven-gord Accessed on 10/06/2019