1.3.5 Proton pump inhibitors (PPI)

Paediatric reflux disease guidance including information regarding the use of PPIs in this population can be accessed here: Paediatric reflux disease guidance

The use of proton pump inhibitors (PPI) and histamine H2 receptor antagonists (H2RAs) has been suggested to be a risk factor for the development of C. difficile-associated disease. PPIs can also increase the risk of fractures (particularly when used at high doses for over a year in the elderly), and may mask the symptoms of gastric cancer. Patients at risk of osteoporosis should maintain an adequate intake of calcium and vitamin D, and if necessary, receive other preventative therapy.

MHRA advice (September 2015): Very infrequent cases of subacute cutaneous lupus erythematosus (SCLE) have been reported in patients taking PPIs. Drug-induced SCLE can occur weeks, months or even years after exposure to the drug. Refer to MHRA advice for management advice.

Measurement of serum-magnesium concentrations should be considered before and during prolonged treatment with a PPI, especially when used with other drugs that cause hypomagnesaemia or with digoxin. All acid-blocking medicines may reduce the absorption of vitamin B12 due to hypo- or achlorhydria. Monitoring may be considered in patients with reduced body stores or risk factors for reduced dietary vitamin B12 absorption on long-term therapy.

PPIs should only be used where there is a clear indication. PPIs should be prescribed at the lowest effective dose for the shortest period; the need for long-term treatment should be reviewed periodically. All PPIs are absorbed in the small bowel (including dispersible tabs); where there is gastric outlet obstruction, IV omeprazole should be used.

For patients who have difficulty in swallowing, some PPI capsules may be opened and their contents dispersed in a suitable liquid. See individual product literature for further advice regarding suitable liquids. Where included in the formulary dispersible tablets may also be prescribed for patients with dysphagia or receiving tube feeding. Dispersible preparations should not be prescribed in any other circumstances. In tube fed patients, lansoprazole dispersible tablets are preferable as omeprazole dispersible tablets are more likely to block fine-bore tubes.

Omeprazole
  • Capsules 10mg, 20mg (£0.91 = 20mg daily)
  • IV infusion 40mg

Indications and Dose

Notes

  1. Omeprazole liquid (unlicensed and expensive) should only be used if the prescribed dose cannot be given using alternative dosage forms (e.g. dose less than 10mg) or for administration through enteral feeding tubes.
  2. In patients with major peptic ulcer bleeding (active bleeding or non-bleeding visible vessel) following endoscopic haemostatic therapy:
    1. Initial intravenous infusion of 80mg over 40 – 60 mins followed by continuous intravenous infusion, 8mg/hour for 72 hours (unlicensed indication).
    2. Alternatively 80mg three times a day (unlicensed indication).
    3. Refer also to NICE CG141: Acute Upper Gastrointestinal Bleeding for further guidance.
Lansoprazole
  • Capsules 15mg, 30mg (£1.26 = 30mg daily)
  • Orodispersible tablets 15mg, 30mg (£4.00 = 30mg daily)

Indications and Dose

Notes

  1. Lansoprazole oro-dispersible tablets are licensed for administration via nasogastric feeding tube. The tablets may be dispersed in a small amount of water and administered via a nasogastric tube or oral syringe. Further instructions are available in the manufacturer's SPC.

 

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