1.3.5 Proton pump inhibitors

General guidance

• Significant numbers of patients remain on treatment doses of these agents without any apparent attempt to step down their therapy.
• Planned step-down should be discussed with the patient upon initiation of treatment and should be carried out if appropriate (see below).
• The National Institute for Clinical Excellence recommends the use of the lowest cost appropriate PPI.

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• Use of Lansoprazole orodispersible tablets (FasTab) is restricted to patients with swallowing difficulties.

• Click here for a print version of the visual above. 

For guidance on Proton Pump Inhibitor De-prescribing Guidance, please click here.

Recommended drugs

Lansoprazole £

Omeprazole £

Clopidogrel and proton pump inhibitors: interaction-updated advice

In light of the most recent evidence, the previous advice on the concomitant use of clopidogrel with proton pump inhibitors has now been modified. Use of either omeprazole or esomeprazole with clopidogrel should be discouraged. The current evidence does not support extending this advice to other PPIs.

Click here for more information MHRA drug safety update April 2010.

Gastro-protection from NSAID induced GI side effects

General guidance

• Individuals vary widely in their ability to tolerate individual NSAIDs, changing patients to a different NSAID is therefore a reasonable action if minor symptoms occur.
• Gastro-protection should not be prescribed routinely, it should be reserved for those at significant risk of gastrointestinal bleeds due to an NSAID and for those unlikely to survive a serious upper GI haemorrhage. Gastro-protection should also be strongly considered for those on a concomitant warfarin and NSAID therapy. Avoid NSAID use in those with a previous NSAID induced GI bleed. Four risk factors have been identified as predictors for serious GI complications with oral NSAIDs:
• Increasing age (especially over 65 years)
• Cardiovascular disease
• History of peptic ulceration
• History of GI bleed
• Other known risk factors are concomitant corticosteroid use, treatment with a selective-serotonin re-uptake inhibitor, severe disability, high NSAID dosage, liver and renal impairment and the first three months of NSAID treatment.
• Cox-II selective inhibitors are associated with an increased risk of thrombotic events and should not be used in preference to non-selective NSAIDs except when specifically indicated (i.e. for patients at a particularly high risk of developing gastroduodenal ulceration or bleeding) and after assessing their cardiovascular risk.
• Patients with significant GI symptoms should be managed by immediate discontinuation of the NSAID and urgent referral for endoscopy.
• Misoprostol 200mcg four times daily reduces serious NSAID induced GI complications by 40%. However, its use at these doses is limited by side effects such as diarrhoea and abdominal pain.
• Histamine H2 receptor antagonists in high doses, equivalent to ranitidine 300mg bd, are associated with a significant reduction in the risk of endoscopically detectable gastric and duodenal ulcers. Standard doses of H2 antagonists (e.g. ranitidine 150mg bd) are only effective at reducing the rate of endoscopic duodenal ulcers. The effectiveness of ranitidine at preventing serious ulcer complications has not been evaluated.
• Proton pump inhibitors reduce the risk of both endoscopic duodenal and gastric ulcers. Maintenance doses of proton pump inhibitors (Lansoprazole 15mg daily) have been shown to give good gastroprotection.

Recommended drugs

Lansoprazole 15-30 mg daily £

Misoprostol 200micrograms four times daily ££

Ranitidine 300mg twice daily ££

Helicobacter pylori eradication

General guidance

• Long term healing of duodenal and gastric ulcers can be achieved by eradicating Helicobacter pylori.
• The beneficial effects of H pylori eradication in other GI conditions are uncertain.
• It is essential that the presence of H pylori be confirmed prior to starting eradication therapy, and that eradication is confirmed, using breath testing, following treatment.
• Treatment failures are most likely to reflect poor patient compliance with the regimen, although resistance to metronidazole or, more rarely, clarithromycin may occur.
• Patients should be advised to stop smoking during eradication therapy since this reduces its success rate.
• Patients requiring more than two courses of H pylori eradication therapy should be referred to a gastroenterologist.  

Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines

Purple – Specialist use/initiation

Red – Non Formulary

Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low