Naproxen and Omeprazole are common drugs prescribed in the UK. Individually both drugs are used in the treatment of different conditions, however many patients who are prescribed naproxen get omeprazole prescribed at the same time. Why are Naproxen and Omeprazole prescribed together?
What is Naproxen used for?
Naproxen belongs to a group of drugs called Non Steroidal Anti-Inflammatory Drugs (NSAIDs). Other common drugs that belong to the NSAIDs class of drugs include:
NSAIDs stop production of prostaglandins, a group of chemical which contribute to symptoms of inflammation and pain; however, prostaglandins have also a broader role in the human body. Production of prostaglandins increases in response to injury or infection. By reducing the production of prostaglandins, NSAIDs reduce pain and inflammation.
Naproxen is indicated in the following conditions (NICE, 2019):
- Pain and inflammation of musculoskeletal nature
- Dysmenorrhoea (painful period pains)
- Onset of gout
- Management of migraines
What is Omeprazole used for?
Omeprazole belongs to a group of drugs called Proton Pump Inhibitors (PPIs). This group of drugs is used mainly in the treatment of acid reflux and Gastro-Oesophageal Reflux Disease (GORD). Other uses include:
- Treatment and prevention of gastric and duodenal ulcers
- Prevention of complications in patients who take NSAIDs continuously, who have a history of NSAID-associated duodenal, gastric ulcers or gastric lesions or symptoms of dyspepsia
- Zollinger–Ellison syndrome
- Treatment of Helicobacter pylori, bacterial infection together with a combination of two antibiotics
Omeprazole is one of the most commonly prescribed drugs in the UK.
Why are Naproxen and Omeprazole are prescribed together?
Treatment with NSAIDs, such as Naproxen, is associated with a number of possible side effects. Some of the most common gastro-intestinal side effects associated with Naproxen use include:
- Peptic ulcers
- GI bleeding or perforation (a hole)
- Heartburn, dyspepsia, abdominal discomfort
As previously mentioned, prostaglandins have a number of roles in the body. Some prostaglandins are present in the stomach lining, where they inhibit acid secretion and stimulate mucus production, thus having a protective role (Wallance, 2008). Since Naproxen stops the production of prostaglandins, patients who take it are at higher risk of gastro-intestinal complications such as GI bleeding, heartburn, and ulcers.
Proton Pump Inhibitors are such as omeprazole, are prescribed alongside naproxen to minimise the stomach acid secretions and consequently to minimise the risk of possible side effects.
Do you need to take Omeprazole whilst on Naproxen?
Patients are generally advised to take Naproxen with or after food to minimise the risk of stomach side effects. This is a preferred method of administration.
Interestingly, no evidence exists to show that taking analgesics with food minimises adverse effects (Moore et al., 2015). A systemic review (a review comparing a large number of studies) on the effect of foods on NSAIDs and other drugs concluded that taking Naproxen with food delays the absorption of the drug and hence prolongs the time it takes to work. Food does not affect how much drug is absorbed (gets into the body) (ibid). Delayed onset of action may not be preferable when a drug is taken to manage acute conditions such as migraine or period pains.
Some patients will be recommended to take omeprazole or another PPI when naproxen is prescribed, see list below.
Official recommendation on the use of Omeprazole when Naproxen is prescribed
The official NICE guideline (NICE, 2019) recommends using gastro-protection (Omeprazole) when NSAIDs such as Naproxen are prescribed in patients who:
- Are at risk of gastro-intestinal side effects, for example, patients needing a long-term treatment with NSAIDs who experience indigestion from standard NSAIDs such as Ibuprofen
Patients who are at risk of side effects associated with the use of NSAIDs include (ibid):
- Patients aged over 65
- Patients with a history of ulcers or stomach bleeds
- Patients prescribed a high dose of NSAIDs
- Patients taking other drugs which can contribute to gastro-intestinal side effects, for example, a common class of antidepressants SSRIs (e.g., Fluoxetine, Citalopram )
- Patients who smoke or drink alcohol a lot
- Patients who experienced side effects with NSAIDs in the past
- Patients who require a long treatment with NSAIDs
Does Naproxen interact with Omeprazole?
Naproxen does not interact with Omeprazole. Both drugs can be taken at the same time.
What are Naproxen gastro-resistant tablets?
Most commonly, Naproxen is prescribed as immediate-release tablets. Naproxen tablets are also available in forms of gastro-resistant (enteric-coated) tablets. Naproxen gastro-resistant formulation is designed to prevent the tablet from breaking down in the stomach and thus minimise the risk of side effects.
Limited studies exist to show the advantages of Naproxen gastro-resistant tablets over immediate-release tablets. Only one study of over 300 patients treated with Naproxen gastro-resistant tables showed better stomach tolerability (reduced number of side effects) than immediate-release tablets in patients with osteoarthritis rheumatoid arthritis (Caldwell & Roth, 1994). Theoretically, it is possible to increase the risk of lower gastro-intestinal side effects, since gastro-resistant tablets are dissolved further along the GI tract (Davies, 1999). Finally, prescribing a combination of immediate-release Naproxen with Omeprazole is much more cost-effective than prescribing Naproxen gastro-resistant tablets, which are several times more expensive.
Alternative options to Omeprazole
Omeprazole is the most prescribed PPI in the UK, and one of the most prescribed drugs overall. Patients, however, may be co-prescribed a different PPI, for example, Lansoprazole or Esomeprazole. Esomeprazole can be purchased over the counter without a prescription from supermarkets and pharmacies. Read Omeprazole alternative drugs or Lansoprazole vs Omeprazole to learn more about different PPIs.
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H2 receptor antagonists, such as ranitidine can also be used, however, with a number of recalls and ongoing investigation into the safety of ranitidine, it is unlikely to get this drug in the UK.
Conclusion on taking Naproxen and Omeprazole together
To conclude, Naproxen and Omeprazole do not have to be co-prescribed to all patients. A certain group of ‘at risk’ patients need Omeprazole treatment when Naproxen is prescribed. In the UK, Naproxen should preferably be taken with food (product license). Always follow the directs of the prescriber.
Can you take NSAIDs with Omeprazole?
NSAIDs such as Ibuprofen and Naproxen can be taken together at the same time. There is no interaction between both drugs.
Can you take Naproxen with antacids?
Naproxen can be taken with antacids. Most manufacturers of antacids advice to leave a gap of two hours between taking Naproxen and using an antacid.
Should Naproxen be taken with Omeprazole?
Not all patients require Omeprazole when Naproxen is prescribed. In the UK it is recommended that a certain group of people have Omeprazole prescribed with Naproxen, for example patients over 65 years of age or patients who previously experienced side effects whilst on Naproxen.
How soon after taking Omeprazole can I take Naproxen?
Omeprazole can be Naproxen can be taken at the same time. Although Omeprazole can affect metabolism of different drugs in the liver, Naproxen is metabolised by different enzymes.
- Caldwell JR, Roth SH (1994). A double blind study comparing the efficacy and safety of enteric coated naproxen to naproxen in the management of NSAID intolerant patients with rheumatoid arthritis and osteoarthritis. Naproxen EC Study Group. J Rheumatol. 1994 Apr;21(4):689-95. Available at: https://www.ncbi.nlm.nih.gov/pubmed/8035394 Accessed on 24//12/2019
- Davies, NM (1999). Sustained release and enteric coated NSAIDs: are they really GI safe? J Pharm Pharm Sci. 1999;2(1):5–14. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10951657 Accessed on 24/12/2019
- Moore Robert Andrew, Sheena Derry, Philip J Wiffen, and Sebastian Straube (2015). Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDs – a systematic review. Available at: https://dx.doi.org/10.1111%2Fbcp.12628 Accessed on 24/12/2019
- NICE (2019). Naproxen: indications and dose. Available at: https://bnf.nice.org.uk/drug/naproxen.html Accessed on 22/12/2019
- NICE (2019). NSAIDs – prescribing issues. Available at: https://cks.nice.org.uk/nsaids-prescribing-issues#!scenario Accessed on 22/12/2019
- Wallance (2008). Prostaglandins, NSAIDs, and Gastric Mucosal Protection: Why Doesn’t the Stomach Digest Itself? Available at: Prostaglandins, NSAIDs, and Gastric Mucosal Protection: Why Doesn’t the Stomach Digest Itself? https://doi.org/10.1152/physrev.00004.2008 Accessed on 22/12/2019