Understanding PPI & H2 Blocker Spacing and the Rationale Behind Taking BOTH for (at least) Fourteen Days
Infantreflux: Dr Phillips, while I have your ‘attention’ 😊…(& I will put this on infantreflux for ‘safe-keeping’)
Can you please explain why it is that we all say (& know it to be true!) to parents of babies who are just starting a ppi “when starting a ppi stay on Zantac (or other h2 blocker) for two weeks because until the ppi ‘kicks in,’ it’s as if your baby isn’t medicated at all!” We also advise them to space the two meds four hrs apart. So: why is it up to 14 days to see the full results of the ppi (assuming it’s a ‘proper’ dose)? We saw the ppi working on day 12 w/ our baby, it was *that* obvious! Why so long when for an adult it may be immediate? Is it that there’s usually so much irritation/damage by the time a baby gets the ppi rx, that it can take up to 14 days to heal and subsequently one can then ‘see’ the results? Thank you; this question keeps coming up &, while I have tons! of anecdotal evidence regarding this, a (broken-down) scientific explanation would really help! 😊
Dr P: Great question: As you know, many infants run into tolerance on H2 blockers. This can begin in as little as a week or less. So, What I typically recommend is: 1. Determine if you are seeing any benefit from the H2 or has it started to wane? 2. Determine if there is really bad nighttime acid that wakes the baby up like at 2 to 4 am? If answer to 1. is “yes” and answer to 2. is yes then just start on the correct dose of the PPI based on weight and age. Give the last PPI dose of the day approx 1 he before you lay the baby down (and as we stated before – burp, burp, burp before laying the infant down anytime of day or night). Now if the H2 is working fine or pretty well, make sure dose of H2 is sufficient. Remember that the ideal use of an H2 (if you are going to use it) is at the last dose of the day (that way the development of tolerance is much less). But really, if the H2 is working sufficiently then you wouldn’t be (most likely) changing to the PPI in the first place. So, most of the time, the H2 has kind of pooped out and I would just switch to the PPI (making sure the dose is sufficient for age and weight. And yes Laura Heller Bennett, you are absolutely correct – The damage takes time to repair and heal AND if you had a failing H2 blocker, then you are kind of close to where you started.
Infantreflux: Yes but why can it take up to 14 days to see the full effects of the ppi?
Dr P: The esophageal mucosa is very sensitive to acid and is damaged easily causing inflammation (yes the is why eosinophils migrate to that location), and sometimes erosions and even ulceration. This takes approx 2 weeks to heal. So what you are often seeing is continued symptoms while healing is occurring (why it is essential to make sure the dose is correct) or you go thru the semi-healed phase much longer.
Infantreflux: Thank you! Next: why do we need to space a ppi & h2 blocker 4 hrs from one another?
Dr P: Ok so remember that the acid pumps have to be in the “on” phase in order for the PPI to block those acid pumps (aka proton pumps). One of the ways that acid pumps get turned “on” is through the action of histamine (which is why kids acid goes crazy when they are teething). If you take a histamine blocker and it is in the bloodstream when the PPI is also in the bloodstream (hence the 4 hour window) then the histamine won’t be able to turn on those proton pumps AND unfortunately the PPI (proton pump inhibitor) will not be able to block the pumps. This is called a drug interaction.
Infantreflux:💥Yay! Thank you! 💥
Dr P: By the way most pharmacists and physicians don’t know this.
Infantreflux: Yes, I know; that’s why I gather and disseminate the info! 😊
Infantreflux: One more (related) question: spacing of antacids (aluminum free liquid Mylanta-type & tums) from delayed release ppis?
Dr P: You will want to space them by a couple hours. The antacids will try to partially disintegrate the PPI when in delayed release form. This will leave the partially disintegrated PPI on the stomach folds (called the rugae) and the acid will get to it and destroy the partially uncoated PPI.
Infantreflux: I’m a happy nerd right now thanks 😊