Your genetics determines the effectiveness of Tecta for you

Tecta (pantoprazole) is one of the most widely used medications for heartburn, acid reflux and stomach ulcers. Most people do well on it, but some get little relief while others take it for years at a higher dose than they need. A major reason is genetics: the CYP2C19 gene controls how quickly your liver clears Tecta and most other proton pump inhibitors (PPIs). Guidelines now recommend adjusting the PPI dose for people with certain CYP2C19 results.

What is Tecta and how does it work?

Tecta (pantoprazole) belongs to a group of medications called proton pump inhibitors, or PPIs. Other PPIs include omeprazole (Losec), esomeprazole (Nexium), lansoprazole (Prevacid), dexlansoprazole (Dexilant) and rabeprazole (Pariet). PPIs block the proton pump, an enzyme in the stomach lining that produces stomach acid. Less acid allows the esophagus and stomach to heal and relieves symptoms.

Tecta is used to:

• treat gastroesophageal reflux disease (GERD), heartburn and reflux esophagitis;
• heal stomach and duodenal ulcers;
• prevent ulcers in people who take anti-inflammatory painkillers (NSAIDs) long term;
• treat Helicobacter pylori infection, together with antibiotics.

Why doesn't Tecta work the same for everyone?

Most PPIs, including Tecta, are broken down in the liver by the CYP2C19 enzyme. Your CYP2C19 genes determine how fast this enzyme works:

• Poor and intermediate metabolizers clear PPIs slowly, so the drug stays in the body longer and at higher levels. PPIs usually work very well for them, but long-term use at a standard dose may expose them to more drug than they need.
• Normal metabolizers usually respond as expected to standard doses.
• Rapid and ultrarapid metabolizers clear PPIs quickly, so the drug may not stay in the body long enough to control acid. They are more likely to have ongoing symptoms or H. pylori treatment that does not work.

What do guidelines recommend?

The Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline gives CYP2C19-based dosing recommendations for omeprazole, lansoprazole, pantoprazole (Tecta) and dexlansoprazole:

• Rapid and ultrarapid metabolizers: start at a 50% to 100% higher dose, especially for H. pylori infection and erosive esophagitis, and monitor whether the treatment works.
• Poor and intermediate metabolizers: start at the standard dose. For long-term treatment (more than 12 weeks), once symptoms are controlled, consider lowering the dose by 50% to reduce the risks of long-term PPI use.

Esomeprazole and rabeprazole depend less on CYP2C19, and there is not yet enough evidence for genetic dosing recommendations for them. Switching to one of these can be an option if Tecta is not working. Always talk to your prescriber before changing your dose.

Why does the right dose matter?

When a PPI dose is too low for your genetics, symptoms may continue and H. pylori treatment may fail. Clearing H. pylori matters: in a large randomized trial with 22 years of follow-up, two weeks of H. pylori treatment with a PPI and an antibiotic lowered the risk of stomach cancer.

When the dose is higher than needed for many years, the risk of long-term side effects may increase. The American Gastroenterological Association advises that people taking PPIs long term have their dose reviewed regularly so they take the lowest dose that controls their condition. Learn more about long-term risks in Tecta side effects and health risks associated with PPIs.

Does CYP2C19 affect other medications?

Yes. CYP2C19 also affects several other commonly used medications, including:

• Clopidogrel (Plavix): a blood thinner that needs CYP2C19 to work. The CPIC guideline recommends another antiplatelet drug for poor and intermediate metabolizers in many situations.
• Antidepressants such as citalopram, escitalopram and sertraline. Read more in Comparison of antidepressants' effectiveness and side effects.
• Voriconazole, an antifungal medication.

Your CYP2C19 result can therefore help with many medications you may take over your lifetime.

Can a pharmacogenetic test help?

Pillcheck reports CYP2C19 along with 23 other genes and 355 medications, which account for over 70% of dispensed prescriptions. A Pillcheck pharmacist reviews your results and all your medications and recommends options and doses to discuss with your prescriber. Your DNA does not change, so your results stay useful for life. Many insurance plans cover Pillcheck; visit our insurance information page for details.

Summary

• Tecta (pantoprazole) and most other PPIs are broken down by the CYP2C19 enzyme.
• Rapid and ultrarapid metabolizers may need a 50% to 100% higher starting dose, especially for H. pylori and erosive esophagitis.
• Poor and intermediate metabolizers on long-term treatment may do well on a lower dose once symptoms are controlled.
• Esomeprazole and rabeprazole depend less on CYP2C19.
• CYP2C19 results also guide clopidogrel, several antidepressants and other medications.

Frequently asked questions

Why isn't Tecta working for me?

There are several possible reasons, including taking it at the wrong time (it works best 30 to 60 minutes before a meal), the wrong dose, or a condition that is not caused by acid. Being a rapid or ultrarapid CYP2C19 metabolizer is another common reason.

Is pantoprazole affected by genetics?

Yes. Pantoprazole is broken down mainly by CYP2C19, and CPIC gives genotype-based dosing recommendations for it.

Which PPI is least affected by CYP2C19?

Esomeprazole and rabeprazole depend less on CYP2C19 than omeprazole, lansoprazole and pantoprazole.

Should I lower my Tecta dose if I am a poor metabolizer?

For long-term treatment, guidelines suggest considering a lower dose once your symptoms are controlled. Talk to your prescriber before making any change.

Can a DNA test tell which PPI is right for me?

Yes. A CYP2C19 result helps your prescriber choose the PPI and dose most likely to work for you, and it also guides other medications.

References

Lima JJ, Thomas CD, Barbarino J, et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2C19 and Proton Pump Inhibitor Dosing. Clin Pharmacol Ther. 2021;109(6):1417-1423.

Freedberg DE, Kim LS, Yang YX. The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017;152(4):706-715.

Li WQ, Zhang JY, Ma JL, et al. Effects of Helicobacter pylori treatment and vitamin and garlic supplementation on gastric cancer incidence and mortality: follow-up of a randomized intervention trial. BMJ. 2019;366:l5016.

Lee CR, Luzum JA, Sangkuhl K, et al. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 Genotype and Clopidogrel Therapy: 2022 Update. Clin Pharmacol Ther. 2022;112(5):959-967.