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  1. #1
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    Default So my friend the gastroenterologist and I got to talking about horses . . .

    . . . after he got done yelling at me about giving aspirin to everyone. (cardiologists and GI docs don't often see eye to eye on the wonders of aspirin therapy)

    Anyhow, I asked him about a few things I've been meaning to try and figure out with all the horse ulcer topics, specifically:

    Is omeprazole really so incredibly fragile that it must be given in the Secret Expensive Formula?

    Is there a "rebound effect" from using PPIs or antacids?

    His answer to the first question was that yes omeprazole is vulnerable in acid but why not do what a lot of the later PPI formulations do, and give the omeprazole along with a sodium bicarbonate buffer? That raises the pH in the stomach for 20-30 minutes, which is about as much time as it takes for oral omeprazole to be absorbed and start doing its thing. Apparently the newest reincarnation of omeprazole (Zegerid) is just that: a combination of omeprazole and good old baking soda.

    The answer to the second question is yes--SUSTAINED use of PPIs can cause a rebound of acid production when the drugs are stopped, but regular antacids do not do this.

    The conversation then turned elsewhere, I won't bore you.
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  2. #2
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    Jan. 7, 2011
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    Default

    Delta, sigh...
    I am so not at your level of intellect. Could you please rephrase to a layman who is interested because she's concerned her older mare may be developing ulcers?
    Thank so much.



  3. #3
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    Default

    I would ask you to start with spelling out PPI's.
    save lives...spay/neuter/geld



  4. #4
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    Feb. 6, 2000
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    Default

    Acid production in the equine stomach is a fairly constant process. Not sure how you could have a rebound effect in that case.
    "It's like a Russian nesting doll of train wrecks."--CaitlinandTheBay

    ...just settin' on the Group W bench.



  5. #5
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    Default

    Quote Originally Posted by fivehorses View Post
    I would ask you to start with spelling out PPI's.

    not delta, but PPI=proton pump inhibitors
    That's the class of drug (mechanism of action) of omeprazole.
    "It's like a Russian nesting doll of train wrecks."--CaitlinandTheBay

    ...just settin' on the Group W bench.



  6. #6
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    Default

    So why not combine PPIs plus other H2 and H1 blockers? (i.e. other acid reducers)

    Combine ranitidine/famotidine/cimetidine + omeprazole...treat ulcers for 2-4 weeks at 20mg/kg (or is it 40mg/kg?) 2x/day, then wean off WHILE keeping on the non-PPI acid reducers?



  7. #7
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    Jan. 16, 2002
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    Default

    Dang, where'd my reply go? Is Merial stalking the BB?

    I guess I figured that even in a model where there is normally full-time acid production, turning it OFF (with a PPI) for a period of time could still potentially give you rebound hypersecretion of acid when you remove the drug, no? Not just full-time acid, but MORE full-time acid?

    My guess is that there are probably MANY different ways to get ulcer meds where they need to go safely and effectively without paying thirty bucks a day or whatever it is. That kind of price is just obscene, and I'll freely admit that I have an axe to grind with pharmaceutical price gouging. It gives me an agenda, no question.

    I wish to God some independent group would do a nice study on buffering cheap old twenty-year-old omeprazole with good old baking soda so horses can be treated more readily without bleeding their owners dry.
    Click here before you buy.



  8. #8
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    Mar. 3, 2010
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    Default

    Quote Originally Posted by deltawave View Post
    Dang, where'd my reply go? Is Merial stalking the BB?

    I guess I figured that even in a model where there is normally full-time acid production, turning it OFF (with a PPI) for a period of time could still potentially give you rebound hypersecretion of acid when you remove the drug, no? Not just full-time acid, but MORE full-time acid?
    I'm no gastroenterologist, but I have taken omeprazole on several occasions. My docs totally blew me off when I said I the acid was much, much, much worse after I stopped the drug. It was unbearable! I'm very leery about taking it again.
    "Rock n' roll's not through, yeah, I'm sewing wings on this thing." --Destroyer
    http://dressagescriblog.wordpress.com/



  9. #9
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    Dec. 22, 2008
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    MA
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    Quote Originally Posted by deltawave View Post
    . . . after he got done yelling at me about giving aspirin to everyone. (cardiologists and GI docs don't often see eye to eye on the wonders of aspirin therapy)

    Anyhow, I asked him about a few things I've been meaning to try and figure out with all the horse ulcer topics, specifically:

    Is omeprazole really so incredibly fragile that it must be given in the Secret Expensive Formula?

    Is there a "rebound effect" from using PPIs or antacids?

    His answer to the first question was that yes omeprazole is vulnerable in acid but why not do what a lot of the later PPI formulations do, and give the omeprazole along with a sodium bicarbonate buffer? That raises the pH in the stomach for 20-30 minutes, which is about as much time as it takes for oral omeprazole to be absorbed and start doing its thing. Apparently the newest reincarnation of omeprazole (Zegerid) is just that: a combination of omeprazole and good old baking soda.

    The answer to the second question is yes--SUSTAINED use of PPIs can cause a rebound of acid production when the drugs are stopped, but regular antacids do not do this.

    The conversation then turned elsewhere, I won't bore you.
    Thanks for this info! I was particularly interested in the part about antacids not having a rebound effect.
    Last edited by Riley0522; Jan. 22, 2011 at 09:00 PM.



  10. #10
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    May. 17, 2003
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    If one tapered off the PPI, rahter than just stopping it, boom, I wonder if the rebound effect would be as profound?

    Riley, I believe the point was that "antacids" DO NOT have a rebound effect.



  11. #11
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    Riley, not to quibble re: rebound effect, but it is NOT ANTACIDS that can produce it, but PPIs. Antacids = TUMS, Rolaids, that sort of thing. A bit of trivia, maybe, but IMO important to distinguish to prevent confusion.
    Click here before you buy.



  12. #12
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    atr, jinx!

    I don't know about the tapering. Physiologically it makes sense. Dang, I should have asked him that one. We're both on call so maybe I'll see him tomorrow.
    Click here before you buy.



  13. #13
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    Nov. 20, 2008
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    Deltawave-I fully agree with you regarding the pricing of Gastroguard. Even if it were $500/month (which would still give the company a healthy profit, I'm sure), it's a lot better than what it costs now to do a month of therapy! I wonder how many people either skip doing the scoping or don't complete the full recommended course of therapy due to the exhorbitant costs?

    I'm also wondering how much we can extrapolate humans vs. horses as far as ulcers/acid production, etc. Although we both possess simple stomachs, there are some major differences between human and equine gastrointestinal tracts.

    Humans are omnivores, able to eat fewer and larger meals. IIRC, our acid production is in response to meals, not continually secreted as in the equine. H. pylori has been implicated in human ulcers, but not equine (there was just a blurb on this on thehorse.com). Are ulcers in humans less prevalent in people who eat smaller meals that are high in fiber(analogous to horses with hay in front of them 24/7)?

    Could there be equine versions of acid hypersecretion diseases? I know that even broodmares have been shown in studies to have ulcers-and they are living the recommended lifestyle for reducing ulcers. But then I think being pregnant 11 months of the year and rebred with foals at their sides probably brings it's own kind of stress.

    I don't know the answers to these questions. These are just some random ponderings.



  14. #14
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    Dec. 22, 2008
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    I know what you guys were saying, antacids do not have a rebound effect. I worded it that I was interested in the topic of antacids having a rebound since I've been hearing it come up more often. I am glad to hear that they DON'T .

    I fixed my first post!



  15. #15
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    Dec. 21, 2009
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    Default

    My dad is also a gastroenterologist and I've asked him a lot of the same questions. He thought nexium would work well for horses- it is esomeprazole instead of omeprazole, but basically the same thing. It's formulated so that the capsule can be taken apart and the power can be put in feeding tubes and such so stomach acid won't destroy it.

    Of course, I haven't talked to any vets about it, and I doubt it is any more cost effective than gastrogard.



  16. #16
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    It's ALWAYS good to be wary about comparing species, but as far as I'm aware the gastric mucosa is pretty close to the same, the methods of acid production similar (although the timing is very different) and the effects of PPIs nearly identical between species. And even with H. pylori, acid suppression is an important part of treatment.

    Sooner or later Gastrogard will go generic, and the price will drop like a rock. And as I've said before, you can put MONEY (no pun intended) on there being a "new and improved" (and patented, of course) product coming out at almost exactly the same time.

    In the meantime, if I had ulcers to treat in a horse I'd personally be inclined to go with a compounding pharmacy with an excellent reputation and give the omeprazole with a big slug of baking soda.
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  17. #17
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    Delta, thanks for this info! I'm a lowly second year student right now, but I was surprised to read your post. We had a guest lecturer last year, a physiologist from another university, that gave our GI lectures and he told us pretty much the exact opposite- you get rebound with antacids and NOT with PPIs (you had me interested enough to go back and double check my lecture notes- that's definitely what he said ). I emailed him about it and will be interested to hear what he says. In the meantime keep us posted if you find out more about tapering, I'd be interested to hear if that's been done with any success.



  18. #18
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    What this guy said was that antacids have such a brief effect (20-30 minutes) that there isn't much time for the change in pH to register in any feedback loops. Whereas long-term acid suppression causes gastrin levels to go up and up. I'd have to look it up myself to check my own thinking--you are MUCH closer in time to learning this stuff than I am!

    Here's a little blurb:
    http://www.medscape.com/viewarticle/705224

    Not sure if it is a predictable thing or an occasional thing, though.
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  19. #19
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    Deltawave, I suppose maybe you could give your Tums treats, then mix your omeprazole pills in with the grain a little while later. OTOH, since it's 2.28 grams omeprazole per tube, how much money do you save by giving 100 pills of 20 mg each day? I haven't checked the prices.

    ETA: omeprazole is unstable in aqueous solution; also, by definition a reputable compounding pharmacy does not break the law, and AMDUCA is pretty clear on this. You would have to make the argument along the lines of "my horse won't take oral meds and I'm going to be tubing this in to him" to have a legitimate excuse for compounded liquid omeprazole. I'd go with the Tums and pills.



  20. #20
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    I honestly have not done the math. I'm not sure buying all those itty bitty "human sized" pills is the way to go at all, although they're available everywhere. As I said, I'd probably find a good compounding pharmacy and have them mix it up. Or ask my F-I-L, who is a pharmacist. But yes, something along the lines of giving the antacid first, then the PPI soon after, give the antacid a chance to raise the pH and then dose the good stuff.

    I also wonder at the seeming dichotomy of the manufacturers insisting that their drug does a fantastic job of reducing acid production over a 24-hour period, followed by their insisting that the drug MUST be given in their Secret Formula because otherwise ALL THAT STOMACH ACID will chew it right up. Hmmmm, if the super drug is suppressing all that acid so well, why wouldn't doses #2 through infinity pass right on through that supposedly acid-free environment. Huh? Huh?
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