If acid suppression is necessary, lifestyle changes should be pursued which are important in reflux disease. People should be advised on:

• Smoking cessation
• Healthy eating and reducing the amount of fat in their diet
• Weight reduction
• Avoiding large meals and bed time drinks before retiring to bed and raising the head of the bed at night

Always review the medications of patients presenting with dyspepsia with a view to possible causes of symptoms.

Encourage people who need long-term management symptoms to reduce their use of prescribed medication step-wise:

• Use the lowest effective dose of proton pump inhibitor (PPI) which controls symptoms or
• Use PPI on 'as-needed' basis for self-management and/or
• Advise people to self-medicate with antacid and/or alginate therapy unless there is an underlying condition or co-medication that needs continuing treatment

Patients should be warned that symptoms may increase for a few days after stopping PPI therapy due to rebound acid secretion, but symptoms will settle again. Weaning the PPI over a few days could be considered to try to prevent this.

See formulary 1.3.5 Proton pump inhibitors (PPI)

See formulary 1.1 Dyspepsia and gastro-oesophageal reflux disease

Review medications for possible causes of dyspepsia. In people requiring referral, suspend NSAID use. See section 10.1.1 for further information on NSAID prescribing.

Think about the possibility of cardiac of biliary disease as part of the differential diagnosis

Consider endoscopy if the person has GORD to screen for Barrett's oesophagus. Do not routinely offer endoscopy to diagnose Barrett's oesophagus.

Northern and Eastern Locality referral guidance for GORD and peptic ulcers can be accessed here.

Acute gastrointestinal bleeding

Immediate (same day) specialist referral should be made for people with significant acute gastrointestinal bleeding.

Do not offer acid-suppression drugs (proton pump inhibitors or H₂-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.

Refer also to NICE CG141: Acute Upper Gastrointestinal Bleeding

People who require urgent referral

See here: Eastern locality Upper gastrointestinal tract 2 week wait referral & Northern locality Upper gastrointestinal tract 2 week wait referral.

People in whom endoscopy is inappropriate

• Under 55 with uncomplicated dyspepsia, no alarm symptoms
• Known to have duodenal ulcer who have responded symptomatically to treatment
• Recently undergone a satisfactory endoscopy for the same symptoms, consider managing people without new alarm signs according to previous endoscopic findings

Acid related dyspepsia:

• Omeprazole 10 - 20mg daily for 2 - 4 weeks
• See 1.3.5 Proton pump inhibitors (PPI)

Interventions for uninvestigated dyspepsia

H₂RAs: Shortages are expected throughout 2020. Please check availability of H₂RAs before prescribing

Review medication for possible causes of dyspepsia and offer lifestyle advice, including promoting continued use of antacids/alginates.

No response or relapse

PPI for 4 weeks and stop:

• Omeprazole 20mg daily
• Offer H₂RA, other than ranitidine, if there is an inadequate response to a PPI.

OR

Offer H. pylori 'test and treat':

• Use stool antigen test
• Leave a 2-week washout period after PPI use, and 4-week period after any antibiotic use, before testing for H. pylori
• Please refer to Eradication of H. pylori in Gastro-intestinal tract infections for information on treatment regimens

The majority of patients with functional dyspepsia (64%) will have persistent symptoms despite eradication, therefore routine retesting is not recommended.

Consider retesting if:

• Compliance is poor
• Initial test performed too soon (within 2 weeks of PPI, 4 weeks of antibiotics)
• Patients with associated peptic ulcer, MALT lymphoma, early gastric cancer (Gastric Intestinal Metaplasia, dysplasia or cancer on biopsies)
• Patients with severe persistent or recurrent symptoms

If retesting, wait at least 4 weeks, ideally 8 weeks, and use the H. pylori stool antigen test

• Offer an H₂RA, other than ranitidine, to control symptoms during this period

See sections 1.3.1 H2-receptor antagonists and 1.3.5 Proton pump inhibitors (PPI)

Consider referral to a specialist service, for people with H. pylori that has not responded to second-line eradication therapy, see Dyspepsia CRG (Northern Locality / Eastern Locality)

Good response: Return to self-care.

Relapse after initial care strategies:

• If symptoms return following initial treatment use lowest dose of PPI to control symptoms.
• Consider 'as needed' treatment.

Step down and step off to antacids and/or alginates whenever possible.

Dyspepsia or reflux-like symptoms with normal endoscopy

H₂RAs: Shortages are expected throughout 2020. Please check availability of H₂RAs before prescribing

(Functional dyspepsia or non-erosive reflux disease)

Manage endoscopically determined functional (non-ulcer) dyspepsia using initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring. Re-testing after eradication should not be offered routinely. Please refer to H. pylori eradication in Chapter 5 for information on treatment regimens

If H. pylori has been excluded and symptoms persist, offer a low dose PPI (e.g. omeprazole 10mg once daily) or H₂RA, other than ranitidine, for 4 weeks.

In either case, if symptoms continue or recur after initial treatment, offer a PPI or H₂RA, other than ranitidine, to be taken at the lowest dose which controls symptoms; discuss with patient using PPI treatment when required to manage symptoms.

Avoid long-term, frequent dose, continuous antacid therapy. It only relieves symptoms rather than preventing them.

See section 1.3 Antisecretory drugs and mucosal protectants

H₂RAs: Shortages are expected throughout 2020. Please check availability of H₂RAs before prescribing

Manage uninvestigated 'reflux-like' symptoms as uninvestigated dyspepsia – see above for guidance.

GORD is defined by NICE CG184 as endoscopically determined oesophagitis or endoscopy negative reflux disease.

Offer people who have GORD a PPI for 4-8 weeks:

• Omeprazole 20mg daily
• Offer H₂RA, other than ranitidine, if there is an inadequate response to a PPI.

If symptoms recur following initial treatment use lowest dose of PPI which controls symptoms; consider using the treatment 'as needed'. Step down and step off to antacids and/or alginates whenever possible.

Offer H. pylori 'test and treat':

• Use stool antigen test
• Leave a 2-week washout period after PPI use, and 4-week period after any antibiotic use, before testing for H. pylori
• Please refer to Eradication of H. pylori in Gastro-intestinal tract infections for information on treatment regimens

Consider retesting if:

• Compliance is poor
• Initial test performed too soon (within 2 weeks of PPI, 4 weeks of antibiotics)
• Patients with associated peptic ulcer, MALT lymphoma, early gastric cancer (Gastric Intestinal Metaplasia, dysplasia or cancer on biopsies)
• Patients with severe persistent or recurrent symptoms

If retesting, wait at least 4 weeks, ideally 8 weeks, and use the H. pylori stool antigen test

• Offer an H₂RA, other than ranitidine, to control symptoms during this period

See sections 1.3.1 H2-receptor antagonists and 1.3.5 Proton pump inhibitors (PPI)

H₂RAs: Shortages are expected throughout 2020. Please check availability of H₂RAs before prescribing

Offer H. pylori eradication therapy to H. pylori positive patients with peptic ulcer disease.

For people using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer PPI (omeprazole 20mg daily) or H₂RA, other than ranitidine, for 2 months and if H. pylori is present, subsequently offer eradication therapy. (See section 1.3.1 H2 receptor antagonists re. suspension of licence for ranitidine).

Offer PPI (omeprazole 20mg daily) or H₂RA, other than ranitidine, for 4 to 8 weeks to people who have tested negative for H. pylori and who are not taking NSAIDs.

Offer repeat endoscopy to patients with gastric ulcer and H. pylori, 6-8 weeks after beginning treatment.

Offer people with peptic ulcer (gastric or duodenal) and H. pylori, retesting for H. pylori 6 to 8 weeks after beginning treatment.

In people with an unhealed ulcer, exclude non-adherence, malignancy, failure to detect H. pylori, inadvertent NSAID use, other ulcer-inducing medication and rare causes such as Zollinger–Ellison syndrome or Crohn's disease.

If symptoms recur following initial treatment, offer a PPI at the lowest dose which controls symptoms, or discuss using the treatment on an 'as-needed' basis. Offer H₂RA, other than ranitidine, if there is an inadequate response to a PPI.

For people continuing to take NSAIDs after a peptic ulcer has healed, discuss the potential harm from NSAID treatment. Review the need for NSAID use regularly (at least every 6 months) and offer a trial of use on a limited, 'as needed' basis. Consider reducing the dose, substituting an NSAID with paracetamol, or using an alternative analgesic or low-dose ibuprofen (1.2 g daily). In patients for whom NSAID continuation is necessary co-prescribe an NSAID (consider a COX-2 selective NSAID) with a PPI. For further information on when to prescribe a PPI alongside an NSAID please see Prescribing non-steroidal anti-inflammatory drugs (NSAIDs).

See section 1.3 Antisecretory drugs and mucosal protectants

Endoscopic evidence of severe oesophagitis

Offer a PPI for 8 weeks to heal severe oesophagitis.

• Omeprazole 40mg (2 x 20mg) once daily

If initial treatment fails consider increasing to a high dose of the initial PPI (40mg omeprazole twice daily), switching to an alternative PPI (lansoprazole 30mg daily), or switching to another high dose PPI (lansoprazole 30mg twice daily).

Offer a full-dose PPI (omeprazole 40mg once daily or lansoprazole 30mg once daily) long-term as maintenance treatment for people with severe oesophagitis.

Consider repeat oesophago-gastro duodenoscopy (OGD) to assess healing. If well, continue maintenance at the same dose.

If the person's severe oesophagitis fails to respond to maintenance treatment, carry out a clinical review. Consider switching to an alternative PPI (lansoprazole 30mg daily) or high dose PPI (lansoprazole 30mg twice a day) and/or seeking specialist advice.

People who have had dilatation of an oesophageal stricture should remain on long-term full-dose PPI therapy.

See section 1.3.5 Proton pump inhibitors (PPI)

Zollinger-Ellison Syndrome

Initially omeprazole 60mg daily, usual dose range 20-120mg daily (doses above 80mg in two divided doses); remain on the same dose long-term.

See section 1.3.5 Proton pump inhibitors (PPI)

Barrett's oesophagus

Offer a PPI:

• Omeprazole 20mg daily

Maintain on the same dose long-term. Increase dose to twice a day in those with unresponsive or poorly responsive reflux symptoms.

Omeprazole 40mg twice daily is used in those with dysplastic or neoplastic Barrett's mucosa, and those whose Barrett's is undergoing radio-frequency ablation (RFA) as per NICE guidance.

Benign oesophageal stricture

Offer a PPI:

• Omeprazole 20mg daily

Remain on the same dose long-term unless endoscopy appearances suggest higher doses are required.

Management of short bowel syndrome and intestinal failure: offer omeprazole 20mg twice daily until resolution.

Omeprazole 20mg-40mg intravenously twice daily may be given if bowel very short and high output difficult to manage. The benefit of intravenous omeprazole should be objectively demonstrated. See section 1.3.5 Proton pump inhibitors (PPI)