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1.3.5 Proton pump inhibitors

Omeprazole capsules, IV           
Lansoprazole fast tabs ( reserved for patients with difficulty in swallowing)
Rabeprazole tablets
Pantoprazole tablets
Esomeprazole tablets (Consultant Gastro-enterologist use only for severe GORD, particularly with stricture - see note)

Notes:

1. PPIs can reduce the effectiveness of clopidogrel – see guidance:
www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=776479

2. PPIs have been associated with a very low risk of subacute cutaneous lupus erythematosus (SCLE) –see DSU

Helicobacter pylori Infection

H. Pylori infection is a major causative factor in the development of duodenal ulcer. There is a strong case for offering eradication therapy to:

  • all patients who have had previous proven duodenal ulcers either by radiology or endoscopy.

  • patients with a history of relapsing duodenal ulcer, currently on maintenance therapy are also candidates.

Evidence of the benefit of eradicating people with non ulcer dyspepsia are scant and it is thought that the risks of treatment and drug resistance outweigh the benefits, as less than 10% of patients will respond.

For “Antibiotic regimes for eradication of Helicobacter Pylori” (Click here for Full Guideline)

Notes:

1. PPIs are the treatment of choice for erosive and stricturing oesophagitis and for both gastric and duodenal ulcer. Prescribing on an "as required" basis should be considered for patients with intermittent symptoms..

2. The dose of proton pump inhibitor should always be reduced to the appropriate maintenance dose where possible.

3. Prescribing on as "required" basis should be considered for patients with intermittent symptoms

4. The most cost-effective proton pump inhibitor with the appropriate license should be chosen. Due to omeprazole now being available in generic form, this is currently likely to be the most cost effective option.

5. The use of dispersible presentations of these products, such as lansoprazole FasTabs and Losec Mups, should be restricted to those patients with swallowing difficulties or with PEG tubes.

6. Guidance is available on when to initiate a PPI with a NSAID (or antiplatelet): link

7. Esomeprazole should be reserved for gastroenterologist initiation only in the following circumstances:

Patients with typical symptoms of severe GORD who have failed to respond to at least two other PPIs, e.g, those who have severe erosive oesophagitis, particularly with stricture, who show modest healing with alternative PPIs. 

8. PPIs and renal toxicity

Although rare, acute tubulointerstitial nephritis (TIN) has been reported in association with all proton-pump inhibitors (PPIs), occurring usually after about 10 weeks of treatment. A decline in renal function is usually noted over a period of days to weeks. There may be associated fatigue, malaise, weakness, nausea, vomiting, anorexia, and weight loss. Classic drug hypersensitivity signs and symptoms, such as the clinical triad of rash, fever and eosinophilia, are seen in less that 10% of patients. Abnormal urine analysis measurements have included haematuria, pyuria, proteinuria and eosinophiluria, although these findings may occur in less than half of patients.

Discontinuation of the PPI is the primary therapy, while corticosteroids are often used but efficacy has not been demonstrated in controlled clinical trials. The majority of patients regain renal function, although not always to pre-TIN levels. As NSAIDs are well known to cause acute TIN, the PPI might be overlooked as the causative agent. In patients showing deteriorating renal function on both an PPI & NSAID, the PPI should be stopped at the SAME time as the NSAID. If there is no improvement in renal function on stopping both drugs the patient should be referred for a nephrology opinion (which may include renal biopsy).

9. PPIs and hypomagnesaemia

Prolonged use of proton pump inhibitors (PPIs) has been associated with case reports of hypomagnesaemia, some serious. Consider measuring magnesium levels before starting PPI treatment and repeat measurements periodically during prolonged treatment, especially in those who will take a PPI concomitantly with digoxin or drugs that may cause hypomagnesaemia (e.g. diuretics). See the Drug Safety Update for April 2012.

10. PPIs and increased risk of bone fracture

There is epidemiological evidence of an increased risk of fracture with long-term use of PPIs. Patients at risk of osteoporosis should be treated according to current clinical guidelines to ensure they have an adequate intake of vitamin D and calcium. See the Drug Safety Update for April 2012.

Link to the BNF section: 1.3.5 Proton pump inhibitors