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Experiments with Omeprazole PPI dosage

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Experiments with dosage and timing

In July 2008 I was diagnosed with a hiatal hernia, a long segment (8 or 9cm) Barrett's oesophagus and severe ulcers above the Barrett's oesophagus area. I had had reflux symptoms most of my life - see My life with gastro-oesophageal reflux.

I was put om 40mG omeprazole once per day. 6 weeks later at a second endoscopy to check progress on the ulcers (not much!) I was told, by the consultant endoscopist "That's not enough - 40mG lasts about 20 hours. You need to take two of those a day." Which I did for some time - about 5 months. But then I thought If 40mG lasts 20 hours, can I take one every 16 hours?

Regime 1 (40mG every 16 hours): so I'd take 40mG at 8 in the morning on getting up, another at around midnight before going to sleep, and a third around 4pm the next day. Then back to 8:am the next day. This worked fine. But see 20mg every 16 hours

But then I thought If 40mG lasts 20 hours, this 16 hour regime is still a bit of an overdose. Let me try 20mg. Maybe it would enable me to do an 8 hour regime:

Regime 2: (20mG or 10mG every 8 hours) 8 am. 4 p.m and midnight. Slightly easier for me to do than regime 1.

So I tested - exactly how long would 20mG last? I was fortunate in this respect as I regurgitated stomach fluid easily, so could tell when it was starting to get acid. I was a little surprised to find that with a 20mG dose, acidity doesn't start until between 17 and 18 hours later! Drugs such as PPIs have a half-life - the time it takes for half the dose to be metabolised. See my list of references on PPIs - their half life.

So in fact 20mG every 16 hours (Regime 1) works as well as 40mG every 16 hours!

Having discovered the half-life effect, I was naturally curious. How long would 10mG last. Experiments showed it lasted about 15 hours. So 10mG every 12 hours (regime 3) is as effective for me as 40mG every 16 hours. Your timing may be slightly different - absorption and clearance (by the liver) can vary slightly from one person to another.

Regime 3: 10mG 8 am and a second at 8 p.m.

Summary: PPI Dosage and timing

The table shows the approximate timing of the various dosage: this is based on my own experiments. Your timing may be a little different but should not vary greatly.
mG Hours
40 20
20 18
10 15
5mG no effect

Note that 5mG doses are not available as this seems to be too low a dose to be effective

Bile reflux

Earlier I said I could easily taste the refluxate. As a dose wore off the sequence would be:

Bile reflux was something I had not experienced before except on rare occasions such as serious vomiting. So I knew the taste of bile (very unpleasant - far, far worse than acid reflux). It was extremely concerning. See My life with gastro-oesophageal reflux for more comments! My page on bile may help you determine if your problems are acid or bile related.

Bile reflux is also extremely dangerous: see my list of references regarding bile

Microdosing with PPIs

A natural progression from learning about PPI half-life and time effectiveness of various doses was to try 5mG. The theory led me to suspect a 5mG dose might last 11 hours or so. I tried it, and as far as the acid was concerned, initially I thought it was effective. But some time after reducing to 5mG doses I experienced a massive nocturnal reflux event which woke me up!

I experienced these nocturnal reflux events:

At the time, these events had little meaning but a subsequent similar series of such attacks occurred when I completely stopped taking PPIs, so (in retrospect) it is clear that 5mG is not enough to fully interfere with the gall bladder's operation and these attacks were caused by normal function returning.

Microdosing may have an effect on acid levels but, looking back on the notes I made at the time, the effect is unclear. Presumably this is why 5mG doses are not available. I had done the experiment by opening a capsule and taking half the grains therein. h

PPIs work by poisoning a particular enzyme in the the cells that produce acid. See my list of references to how PPIs work

Final experiment and quitting PPIs

In early 2012 after nearly 3 years on omeprazole I had a pH monitoring session. This proved that the 5mG doses I had been on were not now working. So I went back to 20mG. But I wondered, did 20mG still last as long as it had (see above) or was tolerance a possibility. So I took a dose and waited...

At this time, I had an almost permanent tickly cough. I had also lost weight so regurgitating stomach fluid to taste was no longer easy. What symptom would I notice first?

The tickly cough stopped! That was enough - I have never taken another PPI (Proton-Pump Inhibitor).

But there was a heavy price to pay: as had happened when I reduced to 5mG doses, I again experienced a very severe and unpleasant series of nocturnal bile reflux events.

PPI tolerance?

So I never completed the final "How long does 20mG omeprazole last?" experiment. But I had the distinct impression that is had not lasted as long as during my first dosage experiment.

PPIs are metabolised by the liver. They are a chemical that the liver thinks should not be present - see my references to Liver metabolism of PPIs. In general with time the liver gradually learns to metabolises such xenotoxins more efficiently, so with time the minimum effective dose may well increase. Or with time, PPIs may well become less effective.

As yet, I have found no technical papers to confirm or contradict this.

Afterword 25th January 2020

I still get an occasional tickly cough - but an antacid tablet cures it! The cough receptors are sensitive to acid and to bile, but an antacid won't touch bile, while it will cure an acid attack.

Sputum tainted by bile.
Sputum tainted by bile.
And I still have an occasional bad night from reflux. When it gets into my airways (LPR or Laryno-Pharyngeal Reflux) it wakes me up, but it doesn't get into my mouth so I can't taste it. So initially I thought it was not bile but pepsin. See my list of references to Pepsin. It is extremely unpleasant and causes a burning sensation which makes me cough. On one occasion (16 March 2018 - I had been off PPIs nearly 6 years) it was so bad that I photographed the expectorated phlegm which was chrome yellow, so it can only have been caused by bile - probably with other digestive fluids from the pancreas. This event took over half an hour for the burning to start to wear off. I was coughing badly for the rest of the day. I have had other similar episodes in Nov 2018, Dec 2018, Oct 2019, Nov 2019 (this one was caused by eating too much Stilton cheese too late at night!) but so far (Feb 2020) no more.

I've not noted all of these bile/pepsin reflux events carefully, but now, after being off PPIs for over 4 years, I have a distinct feeling that these pepsin attacks have been less common recently. But I'm now logging them. I never had these attacks before taking PPIs and they were a definite problem on the two occasions I effectively stopped PPIs. See my Microdosing and Quitting with PPIs.

However this continuing series of bile reflux events implies that my gall bladder, though apparently operating normally most of the time, is going into occasional spasms and therefore its operation had been permanently damaged by the PPIs.

So I still have a hiatal hernia, so I have reflux. But I've lost weight and can cope with the symptoms I have. My symptoms are fewer without PPIs and the papers I have found give me adequate evidence that I am maximising my chances of a long and healthy life.

Afterword 11th of December, 2020

Nearly 9 years afte quitting Omeprazole. I had got used to the occasional bad night - they were distinctly less frequent and less common as time went by, so I had given up even counting logging them. I had also got used to the tichly cough that told me I was refluxing and needed an antacid. But now the tickle seems to have stopped: I still reflux, but when I taste it is is acid. I cannot remember the last time I had the warning tickly cough. Or tasted bile. Howeverthe acid reflux these dayd does taste somehow "cleaner".

I know, during my early experiments, the sequence was - a tickly cough, bile taste, acid taste. So has the tickly cough always been caused by a trace of bile? When last I used to have the tickle I wondered why the acid reflux sometimes came without the tickly cough. If I am correct it has taken nearly 9 years for the effects on by gall bladder caused by 4 years on omeprazole to fully wear off!

I would add that I am now 77 yars old. It is possible that these changes are related to aging. But I strongly suspect that has nothing to do with the effect. Though a younger gall bladder might indeed recover more quickly.

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Page first published: Sunday the 10th of October, 2010
Rewritten: Page first published 27th November 2016.
Last modified: December 12 2020 12:45:11.
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