Pharmacist wants me to stop pantoprazole during Epclusa.

[Jorah]

I'm going nuts, I've been taking losec, pantoprazole (antacids) for many many years but I want the treatment to work. 
I started cutting the pantoprazole in half to start tapering off, because of the huge rebound of acid when you stop. The pharm. didn't like that because they're enteric coated. So for a few days I switched to losec and a ranitidine in the evening.
I got myself rabeprazole that comes in 10 mg dose hoping to taper with that. I had to take a ranitadine tonight because I had a lot of burning and heartburn. Lots of noise and some burping...I'm not doing well with this taper...I lost appetite...
Then pharmacist says that I can take the pantprazole 4 hours later, or the losec together with epclusa..(?)
Is anyone taking or has taken epclusa with antacids and is or was successful? Do studies actually prove that there is a high failure rate with antacids. Has anyone come off the antacids and has not suffered? I have a hiatus hernia, but I don't know if that is the cause of the reflux.

Thanks

[Lynn K]

Your med is not an antacid it is in the same class of medicine as prilosec or Nexium called protein pump inhibitor or PPI there are very specific instructions on how to take Epclusa for patients who are unable to discontinue PPI treatment. The other medicine you mentioned ranitidine is in yet another class of acid reducing meds called H2-receptor antagonists. Simple antacids are for example Tums and Rolaids which also have there own specific instructions.

Basically if you are taking a PPI.

"Velpatasvir solubility decreases as pH increases. Drugs that increase gastric pH are expected to decrease concentration of velpatasvir Coadministration of omeprazole or other proton-pump inhibitors is not recommended. If it is considered medically necessary to coadminister, EPCLUSA should be administered with food and taken 4 hours before omeprazole 20 mg. Use with other proton-pump inhibitors has not been studied."

If you are taking an H2  like ranitidine or famotidine  "H2-receptor antagonists may be administered simultaneously with or 12 hours apart from EPCLUSA at a dose that does not exceed doses comparable to famotidine 40 mg twice daily."

And finally if you are taking antacids like Tums and Rolaids, "Separate antacid and EPCLUSA administration by 4 hours"

See table 2 page 9 for more information on specifics

http://www.gilead.com/~/media/files/pdfs/medicines/liver-disease/epclusa/epclusa_pi.pdf?la=en

I treated with Harvoni but the issues are similar. I was taking Prilosec but stopped during treatment. When my acid reflux became to difficult I would take occasional Tums but well separate from the time I took Harvoni. It was a long 35 weeks of treatment and I surely missed my Prilosec but I made it through.

With treatment sometimes difficult to get insurance to provide and the cost of the meds I didn't want to do anything to risk my sucessful treatment

[Jorah]

The issue is the ledipasivir component of Harvoni requires an acidic environment to be best absorbed.

Your med is not an antacid it is in the same class of medicine as prilosec one nexium called  protein pump inhibitor or PPI there are very specific instructions on how to take Harvoni for patients  Who are unable to discontinue PPI treatment. The other medicine you mentioned  ranitidine is in yet another class of acid reducing meds called H2-receptor antagonists. Simple antacids are for example Tums and Rolaids which also have there own specific instructions.

I use the term antacid loosely, but yes they're PPI and H2. Did you get a big acid rebound when you stopped or you tapered?  If you tapered how long did it take?

However it appears the don't want me to take the ppi with epclusa but 4 hours later...
https://www.hepatitis.va.gov/pdf/acid-reducing-meds.pdf

In The form they recommend to come off completely...

[Lynn K]

"Then pharmacist says that I can take the pantprazole 4 hours later, or the losec together with epclusa?"

That is not correct I looked up Losec and that is called Prilosec in the US. Both of those are PPI's and per the prescribing information sheet for Epclusa as above:

"Coadministration of omeprazole or other proton-pump inhibitors is not recommended. If it is considered medically necessary to coadminister, EPCLUSA should be administered with food and taken 4 hours before omeprazole 20 mg. Use with other proton-pump inhibitors has not been studied."

So both pantoprazole and omeprezole should be taken the same way first take Epclusa with food then wait 4 hours and then take the PPI

It is essential if taking any class of acid reducers such as PPI's or H2 Antagonists or simple antacids like Tums that you do so per the explicit prescribing information for them.

[Lynn K]

Yes sorry I noticed you were taking Epclusa so I heavily edited my prior post where I was referencing Harvoni.

I too have a  hiatal hernia with acid reflux and GERD. I don't take Prilosec contionously just as needed when my acid kicks up. So no I did not experience a rebound. Ok yes using the term loosely however there are very specific instructions for the different classes.

Per the prescribing information if you must take a PPI then the Epclusa should be taken with food 4 hours before taking the PPI .

Yes per the prescribing information they do recommend if possible you stop PPI's entirely.

Like I said I took a lot of Tums at night when I was trying to sleep and the acid would climb up my throat. I took my Harvoni at 3 PM so well separated from the time I would take the Tums

Please confirm this with your treating physician.

[Lynn K]

The best source is the prescribing information sheet it should come with every prescription but it is available online as I posted above. The VA site may not always be up to date if there have been any recent changes

[Jorah]

According to this study PPI's and H2 have no effect on the absorption of Daa's. I wonder if its the same for Epclusa.

Study details

The average profile of the 168 participants in the Ottawa Hospital study was as follows:

age – 56 years
63% men, 37% women
common strains of HCV – genotypes 1a and 1b
doctors had diagnosed cirrhosis in 45% of participants
During the course of the study, the following regimens were used:

sofosbuvir + ledipasvir (with or without ribavirin) – 51%
sofosbuvir + ribavirin – 15%
sofosbuvir + simeprevir (with or without ribavirin) – 31%
other (unspecified) regimens – 3%

Results

Cure rates were generally high in this group of participants—greater than 90%. There was no statistically significant impact of acid-reducing agents on the cure rate of DAA-based regimens. When subgroups of participants were assessed—such as those with the difficult-to-treat genotype 1a or those who had cirrhosis or those who only received sofosbuvir + ledipasvir—there was also no significant impact on cure rates caused by acid-reducing agents.

For the future

To minimize any possible risk that acid-reducing agents might have on cure rates, the Ottawa researchers suggest that the dosing of these medicines be limited to once daily. Furthermore, they encourage doctors who care for people with HCV to reassess their patients’ need for acid-reducing agents.

—Sean R. Hosein

REFERENCE:

DeVreese L, Giguère P, Cooper C. Influence of proton pump inhibitors and H2 receptor antagonists on direct-acting antiviral HCV sustained virologic response. The International Liver Congress, 13-17 April 2017, Barcelona, Spain. Abstract SAT-200

[Lynn K]

This looks like good information but as of now it has yet to be incorporated into current treatment planning you could consider bringing this to your doctors attention and see what their opinion on the subject is then follow your doctor's advice.

 Also please note this study was specific to Harvoni the medicines in Epclusa are different.

[Jorah]

This looks like good information but as of now it has yet to be incorporated into current treatment planning you could consider bringing this to your doctors attention and see what their opinion on the subject is then follow your doctor's advice.

 Also please note this study was specific to Harvoni the medicines in Epclusa are different.

Yes, I' ll show it to them, in the meantime I'm still working on tapering off the PPI's in the next few days I'll cut out the 10 mg ppi and try to take 2 zantac a day, then one. We'll see how it goes. The truth is that I'll be happy to get off those pills...

[davidsconfused]

I treated with Harvoni but the issues are similar. I was taking Prilosec but stopped during treatment. When my acid reflux became to difficult I would take occasional Tums but well separate from the time I took Harvoni. It was a long 35 weeks of treatment and I surely missed my Prilosec but I made it through.

I was taking Lansoprazole which lasts me 2 1/2 to 3 days. There was no take it so many hours before or after the Harvoni so I quit it totally before I started the Harvoni. I only took the Harvoni 12 weeks but it was a LONG 12 weeks without the Lansoprazole. Taking generic Tums so many hours after or before the Harvoni was not a good substitute.

With treatment sometimes difficult to get insurance to provide and the cost of the meds I didn't want to do anything to risk my sucessful treatment

Yea, I wanted to give the Harvoni every chance possible to work and it did. 

[Lynn K]

Yeah I was on Harvoni for 24 weeks because of my treatment history and having cirrhosis.

 Let me tell you it was a long 24 weeks without taking any Prilosec.  Like you said Tums just doesn't cut it. I celebrated finishing treatment by finding the Prilosec bottle and immediately taking a tablet. We sure know how to party

[Jorah]

I was taking Lansoprazole which lasts me 2 1/2 to 3 days. There was no take it so many hours before or after the Harvoni so I quit it totally before I started the Harvoni. I only took the Harvoni 12 weeks but it was a LONG 12 weeks without the Lansoprazole. Taking generic Tums so many hours after or before the Harvoni was not a good substitute.

Yea, I wanted to give the Harvoni every chance possible to work and it did. 

Tums don't help.  I tapered off the PPI and now taking 2 Zantac a day, I'm having a hard time even with the zantac , they don't hold me, I do ok in morning then from afternoon on I keep swallowing to keep the acid down...I woke up at night took gaviscon because it was in my mouth . The pharmacist told me to take the zantac together with the epclusa,  Gilead says the same thing...it doesn't make sense but I'm doing it. I may start cutting the zantac and take a quarter off, to see if I can taper that off too. Coffee makes it worst, I hate it....I'm down to one coffee a day which I LOVE but looks I can't even have that ....I eat healthy 2 salads, measured protein, vegetables  no starches no sugar  so its not that I'm eating crap. No citrus no tomatoes...