If you have searched for a PPI potency chart, you may have noticed that different proton pump inhibitors come in different milligram strengths. These differences can help explain how the medicines are compared, but the number of milligrams does not tell you which PPI will work best for you.
For example, NICE uses 20mg omeprazole, 30mg lansoprazole, 40mg pantoprazole and 20mg rabeprazole as full or standard doses in its GORD guidance. Esomeprazole 20mg was treated as dose equivalent to omeprazole 20mg for the guideline's evidence review, although the licensed starting dose for esomeprazole in GORD is higher in some circumstances.
This guide explains what PPI potency actually means, why different medicines use different doses, how standard doses are compared, and why potency is only one part of choosing a treatment. It also covers interactions and where medicines such as famotidine fit into the picture.
Key things to know
- PPI potency describes how much medicine is needed to produce a particular effect. A lower milligram dose does not automatically mean better treatment
- NICE uses different standard doses for different PPIs, including 20mg for omeprazole and rabeprazole, 30mg for lansoprazole and 40mg for pantoprazole in its GORD dose comparison
- Esomeprazole 20mg was treated as dose equivalent to omeprazole 20mg in the NICE evidence review, although dosing can differ depending on the condition being treated
- A higher or lower milligram dose does not by itself tell you which PPI will control your symptoms better
What Does Proton Pump Inhibitor (PPI) "Strength" or "Potency" Actually Mean?
In pharmacology, potency describes how much of a medicine is needed to produce a particular effect. It is not the same thing as overall effectiveness.
For PPIs, the comparison is mainly about how much medicine is needed to achieve a particular level of acid suppression. This is why different PPIs can have different standard doses even though they are used for similar conditions.
It is easy to look at a smaller number, such as 20mg, and assume that it means a medicine is weaker or stronger than one supplied as 40mg. That is not how these doses should be interpreted. Each medicine has its own dosing range, and the appropriate dose depends on the PPI, the condition being treated and the treatment plan.
NICE uses dose comparisons when reviewing the evidence for GORD and related conditions. These comparisons help healthcare professionals understand how different PPIs relate to one another, but they are not a simple ranking of which medicine is strongest or most effective for every person.
PPI Potency Comparison Chart: Standard Licensed Doses
The table below shows commonly used PPI doses included in NICE guidance for GORD. The exact dose can vary depending on the condition being treated. For example, NICE uses higher doses for severe oesophagitis than for standard GORD treatment. Some doses listed as double doses are also described as off label for GORD.
| PPI | Low Dose | Standard Dose | Higher Dose |
|---|---|---|---|
| Omeprazole | 10 to 20mg | 20mg | 40mg (for some conditions) |
| Esomeprazole | 20mg | 20 to 40mg* | 40mg twice daily |
| Rabeprazole | 10mg | 20mg | 20mg twice daily (off label for GORD) |
| Lansoprazole | 15mg | 30mg | 30mg twice daily (off label for GORD) |
| Pantoprazole | 20mg | 40mg | 40mg twice daily (off label for GORD) |
*The NICE evidence review treated esomeprazole 20mg as dose equivalent to omeprazole 20mg. NICE also notes that 40mg is the licensed starting dose for esomeprazole in GORD in the relevant guidance.
The table is useful for comparing doses, but it should not be read as a straightforward ranking from strongest to weakest. The milligram amount reflects differences between the medicines, while the appropriate dose depends on the condition being treated and the individual treatment plan.
Which PPI Is the Most Potent?
There is no simple clinical answer based only on the milligram strength. Different PPIs use different doses, and NICE considers certain doses to be equivalent for its evidence review.
For example, NICE classifies omeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg and rabeprazole 20mg as full or standard doses for its GORD evidence synthesis. It also treated esomeprazole 20mg as dose equivalent to omeprazole 20mg for this purpose.
Esomeprazole is the S isomer of omeprazole, and differences in how the two medicines are metabolised can affect acid suppression in some studies. However, that does not mean that esomeprazole is automatically the right choice for everyone.
The PPI that is suitable for you depends on factors such as the condition being treated, your other medicines, your medical history and how you respond to treatment.
Which PPI Is the Weakest?
It is better not to describe one PPI as simply the "weakest". Pantoprazole has a higher standard milligram dose than some other PPIs, with 40mg used as a standard dose in NICE's GORD dose comparison. That does not mean it provides inadequate treatment when used at the appropriate dose.
The milligram amount should therefore be viewed in the context of the individual medicine rather than as a direct measure of how effective it will be for you.
Pantoprazole can also be considered when drug interactions are an important factor. For example, NHS Specialist Pharmacy Service guidance advises using lansoprazole, pantoprazole or rabeprazole in preference to omeprazole or esomeprazole when a PPI is needed alongside clopidogrel.
Why the Standard Doses Differ but the Intended Effect Does Not
Each PPI has a different chemical structure and is processed by the body in its own way. These differences help explain why the medicines are supplied at different doses.
The standard doses used in clinical guidance are based on evidence about the amount of acid suppression expected from each medicine. NICE uses dose equivalence when comparing PPIs in its GORD guidance, but the exact dose and treatment schedule can change depending on the condition.
For some conditions, treatment may involve a higher dose or more frequent dosing. This should be decided by a prescriber rather than based on a potency chart alone.
Where H2 Blockers Fit In
Famotidine is an H2 receptor antagonist rather than a PPI. It works in a different way by blocking histamine H2 receptors involved in stomach acid production.
H2 receptor antagonists can be considered in some circumstances when a PPI has not provided enough relief or is not suitable. They are not simply different strength versions of PPIs, so comparing famotidine directly with a PPI by milligrams would not be meaningful.
Famotidine can act more quickly than a PPI in some people, while PPIs are generally used when longer lasting reduction in stomach acid is needed. The right option depends on the symptoms and condition being treated.
Choosing Between PPI Strengths and Options for Acid Reflux
A potency chart can help you understand why PPIs come in different doses, but it should not be used on its own to choose a medicine.
Your prescriber will consider the condition being treated, the severity of your symptoms, other medicines you take, your medical history and how you have responded to previous treatment. The dose may also need to change depending on the condition being treated.
One important interaction involves clopidogrel. NHS Specialist Pharmacy Service guidance advises avoiding omeprazole and esomeprazole with clopidogrel because of a significant interaction. When a PPI is needed, lansoprazole, pantoprazole or rabeprazole are generally preferred.
Do not stop clopidogrel or change your PPI without speaking to your prescriber. The best option depends on why both medicines have been prescribed and your individual circumstances.
| Product | Price |
|---|---|
| Omeprazole 20mg | From £12.99 |
| Losec MUPS 20mg Tablets | From £29.99 |
| Lansoprazole 15mg Capsules | From £5.99 |
| Lansoprazole 15mg Orodispersible Tablets | From £8.49 |
| Pantoprazole | From £5.99 |
| Rabeprazole | From £19.99 |
| Esomeprazole | From £16.99 |
| Famotidine Tablets | From £8.49 |
Prices shown are EverydayMeds' standard listed prices at the time of writing and can change. Check the current price at checkout before you order.
Who Should Be Cautious with PPIs for Gastro Oesophageal Reflux Disease
Whether a PPI is suitable depends on your individual circumstances. The following points are general safety information and do not replace advice from a healthcare professional.
- Anyone who has previously had an allergic reaction to a PPI
- Anyone with significant kidney or liver problems, as treatment may need to be considered carefully
- Anyone with osteoporosis or other fracture risk factors, particularly if a PPI is being used for a long period
- Anyone taking a PPI for a long time, as prolonged treatment can be associated with problems such as low magnesium levels and, in some circumstances, vitamin B12 deficiency
- Anyone who develops persistent diarrhoea while taking a PPI, as PPI treatment has been associated with an increased risk of certain gastrointestinal infections
- Anyone taking clopidogrel, as omeprazole and esomeprazole can interact with clopidogrel and other PPIs may be preferred
- Anyone due to have a gastroscopy or an H. pylori breath or stool test, as PPIs can affect the results of some tests and may need to be stopped beforehand
Depending on the reason for treatment, your prescriber may review whether you still need a PPI after a period of treatment. NICE guidance recommends reviewing treatment and using the lowest dose needed to control symptoms where appropriate.
Most PPIs work best when taken before food, but the exact timing depends on the medicine and your treatment instructions. Follow the directions provided with your prescription or medicine.
New symptoms such as unexplained weight loss, difficulty swallowing, vomiting blood or black, tarry stools should be assessed promptly by a healthcare professional rather than managed by changing your PPI dose yourself.
Medical Disclaimer for Long Term Use
This article is provided for general information only and does not constitute medical advice. It is not a substitute for a consultation with a qualified healthcare professional. Treatment suitability depends on an individual clinical assessment, and your prescriber will determine the appropriate treatment for your circumstances.
If you have questions about your health, medication or symptoms, speak to a pharmacist, your GP or another appropriately qualified healthcare professional. In an emergency, call 999 or go to your nearest A&E.
