Module 7: Pharmacological Management of Cardiovascular Diseases

Transcription

1 Module 7: Pharmacological Management of Cardiovascular Diseases Module Aim This module is an introduction to the pharmacological management of cardiovascular diseases and related risk factors. In this module you will learn what management through medicine means. You will also learn the different classes of medications that are used in CVD management. This module also introduces you to the multiple medication approach for cardiovascular disease prevention and study-associated CV medications. This module contains the following sections: Section 7.1: Introduction to Pharmacological Management of CVD Section 7.2: Common Medications Used in CVD Management Section 7.3: Multiple Medications for CVD Prevention Section 7.4: Diabetes Medications Section 7.5: Entering Medication Information into the Tablet Final September-17 Page 1 of 21

2 Contents Module Aim... 1 Module 7 Pre-test... 3 Section 7.1: Introduction to Pharmacological Management of CVD : Definition of Pharmacology : Role and Implication of Drugs in Managing CVDs... 7 Section 7.2: Common Medications Used in CVD Management : Commonly Used Drugs... 9 I. Statins... 9 II. ACE Inhibitors and ARBs III. Beta Blockers IV. Thiazides V. Aspirin Summary of Common Cardiovascular Medications Other Cardiovascular Medications Section 7.3: Multiple Medications for CVD Prevention Section 7.4: Diabetes Medications Section 7.5: Entering Medication Information into the Tablet Module 7 Post-test Appendix 1: Cardiovascular Medications Final September-17 Page 2 of 21

3 Module 7 Pre-test Instructions: Read the following statements carefully and tick [ ] the appropriate column. If you are unsure of any answer you may tick the Don t Know column. The time allotted to you is 5 minutes. Number Question True False 1 The dosage of a medication is not important. Don t Know 2 Pharmacology is the study of drugs Management of CVD through drugs will not have any impact on disease progression. Some common forms of medications are tablets, capsules, and syrups or liquid. The expiry date of a drug should be ignored and the drug should be given without consideration of this date. Drugs used to manage CVD increase blood pressure and cholesterol levels. 7 Medications have both brand names and generic names. Final September-17 Page 3 of 21

4 Section 7.1: Introduction to Pharmacological Management of CVD In this section, you will learn the definition of pharmacology and understand why drugs are important in the management of CVD. This section will also help you to understand the effects these drugs can have on a person with CVD. Learning objectives at the end of this section you should be able to: Understand the definition of Pharmacology Explain the role of drugs in the management of CVDs Explain what implications drugs can have on CVD This section contains the following subsections: Definition of Pharmacology Role and Implication of Drugs in Managing CVDs Final September-17 Page 4 of 21

5 7.1.1: Definition of Pharmacology Pharmacology is the study of drugs. A drug is any substance that, when taken into the body of a living organism, changes normal body functions. A medicine is a drug taken to relieve symptoms of an illness or to prevent or cure a disease. Medications are generally available as tablets, capsules and syrups or liquids. Tablets and capsules, also commonly referred to as pills, are solids that are to be taken orally, and are given to you either in a blister pack, in aluminum foil, or in a bottle. Syrups are liquids that are taken orally. Injectables are medicines that are put into the body with a needle and are stored within an ampoule or a vial. Figure 1. Commonly available forms of medications Medicine in a Blister Pack Medicine in Aluminum Foil Final September-17 Page 5 of 21

6 It is important to check a few points whenever you come across a medication: 1. The name of the medication It is available in two forms the brand name or the generic name. One is the basic name of the drug and will be the same regardless of the company that manufactures it, whereas the brand name is the one given to a drug by a company trying to market it. For combination drugs, which contain multiple unique medications, two or more generic names will be listed with a single brand name. The name of the drug provided to the participant should always be compared against the doctor s prescription. 2. The strength of the medication Each drug can be available in different strengths, or dosages, which are prescribed according to the participant s condition. The dose a participant takes as well as the frequency should be noted, as medications can be taken multiple times per day at different doses. 3. The expiry date of the medication Medications that are beyond their expiry dates are ineffective and could be dangerous. All expired drugs must be discarded at a local pharmacy. 4. The route of administration Most medications are taken by mouth, but others may be topical (such as a patch that is applied to the skin, or drops to the eye). A medication may also be injected into the skin or muscle. Remember: Medications are available as: Tablets Capsules Syrups or liquids Medications are taken to relieve symptoms of an illness or to prevent or cure a disease. It is important to check the following when coming across any medication: Name Strength Expiry date All expired drugs must be discarded. Final September-17 Page 6 of 21

7 7.1.2: Role and Implication of Drugs in Managing CVDs Medications play an important role in the management of CVD and related risk factors. In order to be as effective as possible, it is necessary for you and participants to be aware of proper doses, their mechanism of action, who should and should not take the medication, and common side effects. It is important to convey that these medications have many benefits for participants with CVD and that a lifelong commitment to these medications is required. CVDs are managed using a combination of drugs. The presented symptoms determine which combination will be most effective. Drugs used in CVD management may act in any of the following ways: Slow down the heart rate to decrease oxygen demand. Make the blood vessels wider (vasodilatation / vasodilation) to help with chest pain (angina). Make the blood less sticky (antiplatelet or anticoagulant action) to prevent clot formation. Lower the blood pressure to decrease work load on the heart. Lower the blood levels of cholesterol to prevent plaque from building up inside blood vessels. Implications of drugs used in CVD management include: Reduction and relief of symptoms such as chest pain or difficulty breathing. Saving lives due to reductions in events such as sudden heart attack and stroke. Preventing urgent admissions to hospital. Delaying and preventing the onset of complications. Preventing further damage to the heart. Helping maintain heart function. Improving quality of life. Activity: Matching Match the listed components with their functions. I. Study of drugs A. Action of a CVD drug II. Must be discarded B. Purpose of a CVD drug III. Lower the blood levels of cholesterol C. Expired medication IV. Helps in maintaining heart function D. Pharmacology Final September-17 Page 7 of 21

8 Section 7.2: Common Medications Used in CVD Management In this section we will discuss different types of drugs used in the prevention and control of CVD. Now that you have an understanding of the definition of pharmacology, the use of medicine, and its available forms, we will use this knowledge to look at specific drugs used in the management of CVDs. The six types of drugs commonly used in CVD management are: statins, ACE Inhibitors, ARBs, beta blockers, thiazides, and aspirin. While it is important to have an understanding and awareness of the following medications, it is not necessary to memorize them. Just familiarize yourself with the medications and their uses. A summary list of CV medications you may encounter is included in Appendix 1. Note that for all of those drugs, one major contraindication (reason for non-usage) would be a known allergy or a serious adverse reaction. Assume for any of the listed drugs that a known allergy would prohibit the participant from taking that drug. Recall that you will be collecting information on participant history of medication allergies and adverse events during the screening process (Module 5). Additionally, pregnancy is also a contraindication to the listed drugs. Therefore, if a female participant is pregnant they would not be prescribed any of the drugs discussed. This is an unlikely scenario since the HOPE-4 program only includes people over 50 years of age. Finally, it is important to note that certain medical conditions are contraindications to cardiovascular medications. In particular, liver and kidney diseases and asthma are contraindications, as specific CV medications can worsen those conditions. This medical history information was also captured in the screening questionnaire (Module 5). Learning objectives at the end of this section, you should be able to: Identify the six drugs commonly used in the prevention and control of CVDs. Understand at a basic level how each drug is used in the management of CVD (indications) and instances where the drug cannot be used (contraindications). This section contains the following subsections: Commonly Used Drugs I. Statins II. ACE Inhibitors and ARBs III. Beta Blockers IV. Thiazides V. Aspirin Other Cardiovascular Medications Final September-17 Page 8 of 21

9 7.2.1: Commonly Used Drugs I. Statins What type of drug is it? Statins are a class of drugs which lower cholesterol levels by limiting the production of cholesterol in the liver. How does it work? Statins are used to slow the progression of heart disease by blocking a substance that the body needs to make cholesterol. Statins may also help the body reabsorb cholesterol which has been built up into plaque on the walls of the arteries. This prevents blockage of the blood vessels (atherosclerosis) and decreases the risk of a heart attack or stroke. Who should be on this drug? Participants with established CVD or at risk of vascular disease should take a statin. Lower risk participants that cannot control their bad cholesterol (LDL), despite changing recommended lifestyle behaviors, would also benefit from a statin. Once a participant starts taking statins, they have to keep taking them for the rest of their life because stopping them will result in their cholesterol levels rising again. Who should not be on this drug (contraindications)? If a participant has any of the following conditions they should not be on this drug: Established liver or kidney disease Taking medications for infections such as HIV and Hepatitis C What are some common side effects? Unexpected muscle pains or weakness Headache Abdominal pain Bloating Diarrhea What are some common drug names? Simvastatin Atorvastatin Pravastatin Rosuvastatin Final September-17 Page 9 of 21

10 II. ACE Inhibitors and ARBs What type of drugs are they? These classes of drugs cause dilation (widening) of the blood vessels, which results in lower blood pressure. They can help with the following health problems: high blood pressure, heart failure, heart attack and atherosclerosis. How do they work? ACE (Angiotensin Converting Enzyme) inhibitors prevent the body from producing angiotensin II, while ARB (Angiotensin II Receptor Blocker) drugs prevent the function of angiotensin II. Angiotensin II affects the cardiovascular system by narrowing blood vessels and instigating the release of hormones that can raise blood pressure. This narrowing of blood vessels can result in heart disease. ACE inhibitors/arbs prevent this action from occurring, thereby making the blood vessels wider. Who should be on these drugs? Participants with high blood pressure, congestive heart failure, diabetes, previous heart attack, and kidney disease, should be on this drug. Who should not be on these drugs (contraindications)? If a participant has any of the following conditions they should not be on these drugs: Severe kidney failure Known allergies to ACE inhibitors or ARBs What are some common side effects? Feeling dizzy Headaches Cough (primarily for ACE Inhibitors and not ARBs) What are some common drug names? ACE Inhibitors: Captopril Lisinopril Enalapril Ramipril ARBs: Telmisartan Olmesartan Candesartan Valsartan Final September-17 Page 10 of 21

11 III. Beta Blockers What type of drug is it? Beta blockers are a class of drugs that treat high blood pressure. They are prescribed after a heart attack to stop future heart attacks, relieve chest pain or pressure, and to decrease heart rate. How does it work? Beta blockers are a class of medications that slow the heart rate and relax the blood vessels so that the heart does not have to pump as hard to circulate blood. Who should be on this drug? Participants who have high blood pressure, congestive heart failure, or have had a heart attack, should take this drug. Beta blockers may also be used to treat participants with atrial fibrillation. Who should not be on this drug (contraindications)? If a participant has any of the following conditions they should not be on this drug: Severe asthma Pulse rate is <50 beats per minute What are some common side effects? Feeling dizzy Slow heart rate What are some common drug names? Propranolol Metoprolol Atenolol Carvedilol Final September-17 Page 11 of 21

12 IV. Thiazides What type of drug is it? Thiazides are a type of diuretic and are more commonly known as water pills. They treat a variety of conditions such as high blood pressure, glaucoma and edema. How does it work? Thiazides help rid the body of salt (sodium) and water. They work by making the kidneys put more salt into the urine. The salt, in turn, takes water with it from the blood. Excretion of water in urine decreases the amount of fluid flowing through the blood vessels, which reduces pressure on the walls of the arteries, reducing blood pressure. Who should be on this drug? Participants with high blood pressure, congestive heart failure, kidney problems and liver problems should be on thiazides. Who should not be on this drug (contraindications)? If a participant has any of the following conditions they should not be on this drug: Severe kidney disease Gout (a condition characterized by recurring swollen, tender, red joints, usually in the big toe) Abnormal blood cholesterol What are some common side effects? Muscle pain and weakness Dizziness Upset stomach Dehydration What are some common drug types? Chlorothiazide Hydrochlorothiazide [HCTZ] Indapamide Metolazone Final September-17 Page 12 of 21

13 V. Aspirin What type of drug is it? ASA, or Aspirin as it is more commonly known, is a type of pain killer that is used to relieve aches and pains. It is used to treat heart attacks and strokes, manage pain, swelling and fever, as well as to treat arthritis and gout attacks. How does it work? Aspirin is an antiplatelet drug, meaning that it makes the blood less sticky by preventing platelets from clumping together and forming clots. This decreases the risk of the formation of blood clots and prevents blockage of blood vessels. Who should be on this drug? Participants that have aches and pains and have suffered a heart attack or stroke could be on aspirin. Participants with atrial fibrillation often take aspirin or a similar antiplatelet medication. Who should not be on this drug (contraindications)? If a participant has any of the following conditions they should not be on this drug: Stomach ulcers (use with caution) History of bleeding problems What are some common side effects? Stomach pain Bleeding from the skin, nose, mouth, and rarely brain Final September-17 Page 13 of 21

14 Summary of Common Cardiovascular Medications Table 1 provides a summary of the common CV drug types discussed in section 7.2 of this module. Table 1. Summary of common cardiovascular medications Drug Type of Drug How it works Contraindications* Examples Blocks a Statin Cholesterol- substance used Liver and/or lowering drug in making kidney disease Simvastatin cholesterol ACE Inhibitor Anti-hypertensive Dilates blood vessels Kidney disease Ramipril ARB Anti-hypertensive Dilates blood vessels Kidney disease Candesartan Beta Blocker Anti-hypertensive Slows heart rate Asthma Atenolol Thiazide Diuretic Decreases Hydrochlorothiazide Kidney disease (water pill) blood pressure (HCTZ) Aspirin Anti-inflammatory Prevents blockage of blood vessels Asthma, ulcer N/A *Contraindications always include allergy to any drug or component of the drug and pregnancy. Medical history of liver or kidney disease, or asthma, is documented during participant screening (Module 5) Other Cardiovascular Medications While you do not need to know the details of every medication used in CVD prevention and control, Table 2 lists some other commonly used medications and their indications (reasons for prescription) that you may come across. Table 2. Other common cardiovascular medications Name Class Indication Lasix or Furosemide Loop diuretic (water pill that is more potent than HCTZ) CHF Calcium channel blocker Amlodipine, diltiazam, (dilates blood vessels to verapamil, nifedipine increase blood flow) Hypertension, angina, arrhythmias Nitroglycerin Nitrate (dilates arteries to Angina, heart attack increase blood flow) Digoxin, epinephrine Inotrope, Antiarrhythmic CHF, atrial fibrillation (other heart rhythm problems) Amiodarone, propafenone, procainamide Warfarin (Coumadin), heparin Antiarrhythmic Anticoagulant (prevents blood from clotting) Arrhythmias (heart rhythm problems) Atrial fibrillation, congenital heart defects, valve problems Final September-17 Page 14 of 21

15 Discussion Questions What happens if a participant is taking a drug that does not appear on your list on the tablet? While screening at a community event, a participant reports that they are taking a medication to lower their blood pressure, but they cannot remember what the medication is. How should you proceed? Final September-17 Page 15 of 21

16 Activity: Matching Match the listed components. Feel free to return to the applicable parts of your text. 1. ACE Inhibitors A) An example of a calcium channel blocker 2. Contraindication of Beta Blockers B) Liver or kidney disease 3. Statins C) Stomach ulcers 4. Thiazides D) Prevents blockage of blood vessels 5. Beta Blockers E) An example of a beta blocker 6. Contraindication of Aspirin F) Cause dilation of the blood vessels 7. Aspirin G) An example of an ARB 8. Contraindication of Statins H) Lowers cholesterol levels 9. Atenolol I) Asthma 10. Ramipril J) Water pills that rid the body of salt 11. Amlodipine K) Slow heart rate, relax blood vessels 12. Telmisartan L) An example of an ACE Inhibitor Final September-17 Page 16 of 21

17 Section 7.3: Multiple Medications for CVD Prevention There is overwhelming evidence supporting the effectiveness of anti-hypertensive and lipid-lowering therapies in CVD prevention, with low risk of serious adverse effects. Recently, many experts in the field have suggested using multiple medications for primary cardiovascular prevention in patients with at least a moderate risk for cardiovascular events. This strategy has to do with the global approach to assess and reduce overall CVD risk of the participants, rather than treating specific parameters, such as LDL (bad cholesterol), blood pressure, or pre-existing cardiovascular conditions (which are already often widely treated with multiple medications). All the eligible participants of the HOPE-4 program are considered to be at high risk for CVD due to hypertension and being older than 50 years old. Strong evidence regarding lipid-lowering therapy suggests that the reduction of cardiovascular risk is proportional to the reduction of cholesterol levels, independent of the initial amount of cholesterol in the blood. In other words, lipid-lowering medications (statins are considered the most potent ones) reduce CVD risk even if the participant has a previously normal lipid profile according to blood tests. This reduction in risk is proportional to the medication-mediated reduction in cholesterol levels. Consequently, patients who have suffered major cardiovascular events (such as heart attack or stroke) may receive statins at high doses, independent of their lipid levels. This justifies the possible use of statins in specific participants of the HOPE-4 program, regardless of their previous cholesterol levels. Hypertension is usually a chronic condition that requires lifelong treatment. It is also known that low doses of multiple medications are more effective in controlling blood pressure levels compared to single medications at high doses. Furthermore, adverse effects of drugs are usually the result of overdosing of a particular drug, which is more likely to happen using a single component to control blood pressure. Combination medications reduce the number of required pills that a patient must take, so it is easier for them to keep track of their daily medications, and it is also easier for health care workers to administer combination medications. As a result, in the absence of contraindications, it is expected that participants within the intervention communities of the HOPE-4 program should receive combinations of optimal medications for cardiovascular disease prevention, including but not limited to: Anti-hypertensive Medications: o ACE Inhibitors or ARBs o Diuretics including thiazides o Beta blockers o Calcium channel blockers Cholesterol Lowering Medications: o Statins As a component of your treatment plan for each intervention community participant, you may recommend study-associated medication therapy, according to the participant s medical history and screening assessment of their CVD risk (Module 5). Study-associated medications will typically be locally obtained, from commercial supplies, and therefore the methods for treatment recommendation will be Final September-17 Page 17 of 21

18 adapted for each study country. Prescription of study-associated medication(s) will be at the discretion of a local study physician. Eligible participants that are already taking a CV medication may also transition to study-associated medication. Any side effects of the prescribed study-associated medications will be monitored (Module 5), and a participant s treatment plan may change accordingly. Section 7.4: Diabetes Medications As you learned in Module 4, diabetes is a major risk factor for developing CVD, so we are interested in collecting information about diabetes medications that participants are prescribed. Diabetes drugs work by improving sugar absorption, increasing sugar excretion, or by managing insulin levels in the body. The overall effect of these medications is a reduction in blood sugar levels. These medications are often administered by injection (e.g. insulin), or orally in pill form (e.g. metformin). Some diabetes medications, like CV medications, are also used in combination to improve the effectiveness of a patient s treatment regimen. Generic names of medications used to manage diabetes are summarized below. You are NOT required to memorize these drug names or classes. Insulins insulin aspart insulin degludec insulin detemir insulin glargine insulin glulisine insulin lispro human insulin (NPH insulin) animal insulins (beef, pork) Biguanides buformin metformin phenformin TZDs (Thiazolidinediones) pioglitazone rosiglitazone troglitazone Alpha Glucosidase inhibitors acarbose miglitol voglibose Sulfonylurea derivatives acetohexamide carbutamide chlorpropamide glibenclamide/glyburide glibornuride gliclazide glimepiride glipizide gliquidone glisoxepide glymidine metahexamide tolazamide tolbutamide GLP-1 agonists exenatide liraglutide lixisenatide DPP-4 inhibitors alogliptin gemigliptin linagliptin vildagliptin saxagliptin sitagliptin Gliflozins canagliflozin dapagliflozin empagliflozin Meglitinides nateglinide meglitinide repaglinide Other benfluorex pramlintide Final September-17 Page 18 of 21

19 Section 7.5: Entering Medication Information into the Tablet You will record medications that a participant is taking by using a drop-down menu on the tablet that references a database of medication names. When using the drop-down menu to search for medications on the tablet, you must type in four alphabet characters with the keypad before the menu lists suggested medication names. Initially search by the Generic Name of the medication, if it is not a combination medication. For combination medications (i.e. drugs that contain multiple individual drug components; multiple generic names are listed on the prescription label), search by the medication Brand Name. If you are unable to find the combination medication, try searching for the generic names of each combination medication component. If the generic name and brand name of a medication do not appear in the drop-down menu on the tablet, select the Other option and manually enter the Generic Name of the medication. Remember that you need to enter at least four alphabet characters before this option will appear. Then enter the participant s provided details into the Other/Unknown field. In the HOPE-4 program, you do not need to collect information on non-cardiovascular medications that are common supplements like vitamins, minerals, fish oils, herbal remedies, or diet pills (Table 3). If you are unsure whether or not to record a medication in the tablet, you can speak with your coordinator, or record it and let the supervising physician decide if it is relevant later on. Your coordinator may provide you with a further list of medications that do not need to be recorded. Table 3. Examples of medications that do not need to be recorded in the tablet Name Vitamins Minerals Fish Oils Herbal remedies / Supplements/ Diet pills Examples may include Vitamins A, B 6 [folic acid], B 12, C, D, E and K Iron, calcium, zinc and magnesium Cod liver oil and Omega 3/6 oil Gingko, Echinacea and St John s Wort In addition, please do not enter medications for which the participant does not have the medication bottle or a written list of medications on hand. If the participant does not have access to their medication information during the screening visit, arrange to collect medication details at a later time. However, please remember that anti-hypertensive medications (automatically assessed by the tablet) are considered in the criteria for study eligibility, so it may be necessary to obtain medication information before determining eligibility (see Module 8 for details on eligibility). Final September-17 Page 19 of 21

20 Module 7 Post-test Instructions: Read the following statements carefully and tick [ ] the appropriate column. If you are unsure of any answer you may tick the Don t Know column. The time allotted to you is 5 minutes. Number Question True False Don t Know 1 Statins are not useful in patients with normal serum lipids. 2 ACE inhibitors and ARBs lower cholesterol levels. 3 Thiazides are used for lowering blood pressure. 4 ACE inhibitors are strong diuretics. 5 Beta blockers help slow the heart rate down and relax the blood vessels. 6 ACE inhibitors may cause a cough in patients. 7 Beta blockers are contraindicated in patients with severe asthma. 8 Statins usually increase blood pressure levels. 9 ARBs narrow blood vessels and increase blood pressure. 10 Aspirin makes blood less sticky, decreasing the risk of blood clots and blood vessel blockages. 11 Calcium channel blockers widen blood vessels. 12 Combinations of CV medications are less likely to improve patient health and more likely to have toxic effects, in comparison to a single CV medication. Final September-17 Page 20 of 21

21 Appendix 1: Cardiovascular Medications Angiotensin-Converting Enzyme (ACE) Inhibitors Benazepril Captopril Cilazapril Delapril Enalapril Fosinopril Imidapril Lisinopril Moexipril Perindopril Quinapril Ramipril Spirapril Temocapril Trandolapril Zofenopril Calcium Channel Blockers Amlodipine Diltiazem Verapamil Short Acting Dihydropyridine: Nifedipine regular release Long Acting Dihydropyridine: Amlodipine Felodipine Nifedipine Anticoagulants Unfractionated heparin Low Molecular Weight Heparin: Dalteparin Enoxaparin Nadroparin Tinzaparin Other: Danaparoid Fondaparinux Warfarin (Coumadin) Direct Thrombin Inhibitors: Argatroban Bivalirudin Lepirudin Ximelagatran Angiotensin Receptor Blockers (ARBs) Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmesartan Tasosartan Telmisartan Valsartan Diuretics (including thiazides) Acetazolamide Amiloride *Bumetanide Chlorthalidone *Ethacrynic acid *Furosemide (Lasix) Hydrochlorothiazide or HCTZ Indapamide Metolazone Spironolactone Triamterene *Loop diuretics Inotropes (antiarrhythmics) Epinephrine (adrenaline) Isoprenaline (isoproterenol) Norepinephrine Digoxin Dobutamine Dopamine Inocor Dopexamine Antiplatelet Agents ASA (aspirin) ASA/dipyridamole Clopidogrel (Plavix) Ticlopidine Gp IIb/IIIa Inhibitors: Abciximab Eptifibatide Tirofiban Beta Blockers Acebutolol Atenolol Betaxolol Bevantolol Bisoprolol Carvedilol Celiprolol Epanolol Esmolol Labetalol Metoprolol Nebivolol Nadolol Oxprenolol Pindolol Practopril Propranolol Sotalol Talinolol Timolol Lipid-Lowering Agents Statins: Atorvastatin Fluvastatin Lovastatin Pravastatin Simvastatin Rosuvastatin Fibrates: Benzafibrate Fenobibrate Gemfibrozil Other: Cholestyramine Colestipol Ezetimibe Niacin Proton Pump Inhibitors Omeprazole Lansoprazole Dexlansoprazole Esomeprazole Pantoprazole Rabeprazole Note that combination drugs (multiple drugs in a single pill) are available for some of these medications. Final September-17 Page 21 of 21