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chrisrob
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Quote chrisrob Replybullet Posted: 12 May 2011 at 8:55am
I'm sorry, Richard, I don't want to start an argument on an open forum.

I have discussed the issues of dosage and efficacy extensively with some of the country's top gastroenterologists. They agree that the timing of dosage throughout the day is not important and that there is a delay (of about 3 days) in their effect.

They do NOT reduce acid immediately.

Please do not make assumptions about what the medical profession knows or acknowledges.There are many learned experts who have spent many years studying and researching the points you are attempting to debunk.

It could be dangerous for an unqualified lay person to provide conflicting advice.
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Quote johnd Replybullet Posted: 12 May 2011 at 10:18am
If I could gently stick my head 1mm above the parapet....

I think the original poster's issue is why the PPI's don't seem to be working. It could be just a matter of plugging away whilst the ulceration (about which I have to confess I know nothing) starts to subside. I take it you are Omeprazole 40mg, I know the gastro's do have the option of switching to another type of PPI, increasing the dose of PPI's, and adding a different type of inhibitor Rantidine (Zantac). Thats for the professionals to judge. But the acid really ought to be greatly reduced by now.

For me, a 10 or 20 Omeprazole knocks it out in under a day. Given what I read here, I am on the lookout for any side effects like bile reflux or anything else, and can't sense any. All that seems to happen is they just calm my tummy in a wonderful serene way. Still, you don't want to know about me.

Richard believes that PPI's cause bile reflux and therefore you have to careful not to take to much. I don't know whether this theory is valid or not, I have thought about a lot and I haven't made up my mind. But maybe you should ask yourself whether you are experiencing bile reflux, which should be obvious I would have thought. If you are not, then you should discuss with your GP or consultant (if you can get hold of him/her!) why your symptoms are not starting to subside.

<Duck>
55yo, diagnosed 2011 at 5cm Barrett's, 3cm as at 2013 (?), so far non-D
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RichardT
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Quote RichardT Replybullet Posted: 12 May 2011 at 10:42am
Chris

No argument, I'm after facts. And differentiating facts from opinions!

Actually I have found a very relevant paper:
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2036.2000.00788.x/full
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2036.2000.00788.x/pdf

It basically supports both our view points - depending on how you view the results.

It's quite technical but does explain how the drugs take a time to build up, and how they have a long decay. Also how the 1 hour 'official' half-life differs from my own experimental findings.

It also finds significant differences in the various PPIs.

Although they say PPIs do have a short half life (about 1 hour), what they either haven't realised - or haven't explained is that a short half-life logically implies maximum efficiency (i.e. minimum overall drug intake) is accomplished by taking frequent small doses!

I am still after research facts that prove or disprove that. Until I find facts, the only assumption I can make is that the medical profession are also making assumptions!

Fact: I had bile reflux on high (standard) doses. I do not on frequent small doses.

It also finds that food affects absorption of lansoprazole, but less so with omeprazole and pantoprazole.

I have not finished reading it yet, it's a long and quite technical paper!
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RichardT
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Quote RichardT Replybullet Posted: 12 May 2011 at 11:37am
> Richard believes that PPI's cause bile reflux and therefore you
> have to careful not to take to much.

You read a little too much into my words!

Bile reflux is a proven possibility on Omeprazole: there are plenty of research papers that find it happening and show how and why it could be caused! I have linked to some of them on my www site.

In myself, yes, Omeprazole did indeed cause bile reflux.

Which does not imply that it is going to happen to everyone. Or that I think it will.

It also seems to be believed by the establishment that most people can't tell whether it is acid or bile that is causing their own troubles. I am lucky here - I can tell the difference.

So it's sensible to be aware of the possibility!

Bile reflux seems to be overlooked by most of the medics. Apparently because they cannot control it.

Others here have had various side effects. Logic says that to minimise any side effects, one should also minimise total intake of the drug.

Everything I have found says that for best effect with minimum intake one should take little and often. Lstest evidence is that yes, you need to take high doses initially.

I have yet to find any research that says exactly what the minimum dise rate and frequency is - that probably will vary from person to person. It's also difficult to find as there are several different time delays involved.

Yes - I appear dogmatic about this - because I am after facts. The opinions expressed do not agree with the facts I have found!

Yes: be aware of the facts and discuss with your consultant. Please let me know of any contradictory evidence. I am not concerned with contradictory opinions!
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Mercury
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Quote Mercury Replybullet Posted: 12 May 2011 at 12:13pm
I AM SORRY, GENTLEMEN, THAT I SEEM TO HAVE STARTED A SPAT WITH MY VERY INNOCENT QUESTION!
 
What I have taken from all you say is that:
a) I am on a long road to feeling better (though 'recovery' is very unlikely) and this is very much in my hands,  I must test for myself what food and drink causes me trouble and what does not - everyone reacts differently.   I have started being very scientific about it as of this morning!    I will take note and put a cross next to anything which makes me feel worse!
 
b) The Omeprazole 40mg may be causing me as much (or more) trouble than it is saving, and I must discuss this with my GP.   Certainly, it should by now have sorted my acid reflux, so it may be bile reflux that I am now experiencing.
 
c) I must try to get a more sensible dialogue with my consultant, but rely on myself and my GP to get through this.  This morning, after I pestered her, my GP has agreed to get hold of the consultant, and then I am going to see her next week to put together a plan of campaign.  
 
All this is thanks to everything I have read on this excellent forum/site.
 
So thank you - I do not feel so alone anymore, but I do find your strength of feelings a little daunting!    I think I will stay with johnd, with my head firmly below the parapet!
Ali
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chrisrob
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Quote chrisrob Replybullet Posted: 12 May 2011 at 12:51pm
I'm pleased if we are able to help, Ali.

This is a patietnts forum and non of us are clinicians which is why there is the important yellow warning banner at the top of the page.

I hope your consultant is able to proffer useful advice for your particular case.

All the best

Chris
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RichardT
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Quote RichardT Replybullet Posted: 12 May 2011 at 2:41pm
> I AM SORRY, GENTLEMEN, THAT I SEEM TO HAVE STARTED A SPAT
> WITH MY VERY INNOCENT QUESTION

Not at all. A bit of disagreement is not at all harmful. Keeps the forum awake, I think. Questions that make people think can never be bad - though some professionals (in any profession) do take umbrage at them. But - no professionals here!

In fact, I don't think Chris and I do disagree in essense - but I am a lot more sceptical than is he. I have never tended to take opinion at face value, but always tend to ask 'why?'.

> The Omeprazole 40mg may be causing me as much (or more) trouble than it is
> saving, and I must discuss this with my GP.

For anyone on 24 or 12 hourly doses, I would always suggest spreading that. Your GP could hardly object to you taking 2 x 20mg.Or even 3 (or 4)10mg doses.

As I've sid before - there appear to be no studies to establish minimum effective dosage rate.

Good luck. But at least you have some sensible questions to ask!
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Quote bobby Replybullet Posted: 16 May 2011 at 10:30pm
Originally posted by RichardT

> Richard believes that PPI's cause bile reflux and therefore you
> have to careful not to take to much.

You read a little too much into my words!

Bile reflux is a proven possibility on Omeprazole: there are plenty of research papers that find it happening and show how and why it could be caused! I have linked to some of them on my www site.

In myself, yes, Omeprazole did indeed cause bile reflux.

Which does not imply that it is going to happen to everyone. Or that I think it will.

It also seems to be believed by the establishment that most people can't tell whether it is acid or bile that is causing their own troubles. I am lucky here - I can tell the difference.

So it's sensible to be aware of the possibility!

Bile reflux seems to be overlooked by most of the medics. Apparently because they cannot control it.

Others here have had various side effects. Logic says that to minimise any side effects, one should also minimise total intake of the drug.

Everything I have found says that for best effect with minimum intake one should take little and often. Lstest evidence is that yes, you need to take high doses initially.

I have yet to find any research that says exactly what the minimum dise rate and frequency is - that probably will vary from person to person. It's also difficult to find as there are several different time delays involved.

Yes - I appear dogmatic about this - because I am after facts. The opinions expressed do not agree with the facts I have found!

Yes: be aware of the facts and discuss with your consultant. Please let me know of any contradictory evidence. I am not concerned with contradictory opinions!
It's my opinion that you are not dealing with facts Richard, merely your own personal specifics. Individuals will all have differing affects from medication, I'm taking the view of the professionals on it.
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RichardT
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Quote RichardT Replybullet Posted: 17 May 2011 at 10:58am
> Richard believes that PPI's cause bile reflux and therefore you
> have to careful not to take to much.

A bit more on that. Reading the report
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2036.2000.00788.x/full
I quote
"There is a poor correlation between maximal plasma drug concentration (Cmax) and the degree of acid suppression in studies of omeprazole. The maximal plasma drug concentration varies widely depending on the rate of passage in the gastrointestinal tract, release of drug and intraduodenal pH. However, the area under the plasma concentration–time curve (AUC) does correlate well with acid suppression"

Now a dose onece per day will lead to a high initial level in the blood plasma - (Cmax above). This blood level will fall as the liver metabolizes the drug and the "concentration–time curve", above, is what you get if you draw a graph of blood level with time.

Taking, for instance, 20mG once per day will give a certain high peak concentration a few hours later. Taking that same 20mG as 4 separate 5mG doses will drastically reduce the peak concentration but should, I suspect, result in a very similar "area under the curve". Which is the important bit!

My own experience here suggests very strongly that bile reflux and rebound acidity (and probably other side effects), are indeed related to the peak plasma concentration rather than to the area.

My findings aren't so much about reducing the total intake as about applying that amount to best effect.

It's a subject for raising this Friday.

Edited by RichardT - 17 May 2011 at 11:56am
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chrisrob
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Quote chrisrob Replybullet Posted: 17 May 2011 at 12:16pm
Richard,
You say, "Bile reflux seems to be overlooked by most of the medics." Where do you get that assertion? All the medics I know take bile reflux extremely seriously.

Richard, whilst I admire your studious interest of the condition, I wonder whether this is the right forum for your theories when there may be the risk they could cause patients to disregard their specialists' advice?

You have selectively quoted above from a report mentioning "maximal plasma drug concentration" whilst missing the statement, "the duration of acid inhibition is relatively long (48–72 h)" which supports my consultants' declaration that the timing of PPI ingestion makes no difference.
I do see your point of view about wishing to minimise possible reaction to large doses but please do not espouse your theories as a course of action for others to follow: you are not a doctor.

Anyone wishing to alter the timing or quantity of their drug regimen should discuss it with their GP or GI specialist.

PS. I'm as much against taking drugs unnecessarily as the next man - probably more so, which is why I opted for fundo. And when my GP tried to up my statins, I stopped taking them altogether with the result my cholesterol levels actually fell.

PPS Give my regards to Rebecca when you see her.
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