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1.4 Disorders of gastric acid and ulceration

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

4.1 Dyspepsia

 

Useful resources

 

National Guideline

NICE CG184: Gastro-oesophageal reflux disease and dyspepsia in adults - investigation and management (November 2014)

 

 

Alginates 

Potassium bicarbonate with sodium alginate

Gaviscon Advance 

  • Chewable TabletsSF (Contains 2.25 mmol of sodium, plus 1 mmol of potassium per tablet) 
  • SuspensionSF (Contains 2.3 mmol of sodium, plus 1 mmol of potassium per 5mL)  

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

 

Gaviscon Infant 

  • Oral powderSF (Contains 0.92 mmol of sodium per dose) 

Important: Each half of the dual-sachet is identified as ‘one dose’. To avoid errors prescribe with directions in terms of "dose". 

 

 


Antacids

Antacids with a low sodium content should be used in patients with severe renal, hepatic or cardiac failure.

Co-magaldrox 

  • Hospital preference: Mucogel® SuspensionSF 500mL ('Low Sodium' - sodium content less than 1mmol per 10mL dose)
  • Primary care to specify most cost-effective brand 

 

 

 

4.2 Gastric and duodenal ulceration 

Peptic Ulceration

Helicobacter pylori infection

Recommended regimen:  

Omeprazole 20mg bd, Amoxicillin 1g bd and Clarithromycin 500mg bd for 1 week

 

  • If the patient is penicillin allergic, then substitute metronidazole 400mg bd for amoxicillin and reduce the clarithromycin dose to 250mg bd.
  • Simvastatin should be stopped for the duration of the eradication, due to the interaction between simvastatin and clarithromycin.
  • Following eradication of H. pylori associated with duodenal ulcers uncomplicated by haemorrhage or preforation, the British Society of Gastroenterology (BSG) recommend that continued proton pump inhibitor (PPI) is not required.
  • Two-week triple therapy regimens offer the possibility of higher eradication rates compared to one week regimens but adverse effects are common and poor compliance is likely to offset any possible gain.

 

 

Gastroprotective Complexes and Chelators

Chelates and complexes 

Sucralfate 

  • Tablets 1g
  • Oral SuspensionSF 1g in 5mL 

Notes: 

  • Current supply problem with tablets and suspension unlikely to be resolved until further notice
  • Sucralfate is infrequently used for prophylaxis of stress ulceration and for biliary reflux and oesophageal varices.
  • Following reports of bezoar formation associated with Sucralfate, the CSM has advised caution in seriously ill patients, especially those receiving concomitant enteral feeds or those with predisposing conditions such as delayed gastric emptying.  

 

  

H2-receptor antagonists

Ranitidine 

  • Tablets 150mg, 300mg
  • Effervescent tablets 150mg, 300mg
  • Oral solution 75mg/5mL
  • Injection 25mg in mL, 2-mL amp 

Notes:

  • Ranitidine 150mg tablets should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

 

Proton pump inhibitors

 

Esomeprazole

  • Capsules 20mg, 40mg

 

Lansoprazole

  • Capsules 15mg, 30mg
  • Dispersible tablets 15mg, 30mg 

 

Omeprazole

  • Capsules 10mg, 20mg, 40mg
  • Dispersible tablets 10mg, 20mg, 40mg
  • Intravenous infusion, powder for reconstitution, 40-mg vial 

Notes:

  • Omeprazole 10mg capsules for indegestion / heartburn should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

Indication Omeprazole (capsules)
Treatment and maintenance of Gastro-oesophageal reflux disease 20mg OD for 4 weeks then symptom review
NSAID associated ulcers 20mg OD for 4 weeks. Further 4 weeks if not healed.
NSAID Protection 20mg OD
Duodenal ulcer (Hp eradication) 20mg BD for 7 days
Duodenal Ulcer 20mg OD for 4 weeks
Maintenance of recurrent ulcers 20mg OD
Acid related dyspepsia 10mg-20mg OD for 2-4 weeks
Gastric ulcer (Hp eradication) 20mg BD for 7 days
Gastric Ulcer 20mg OD for 8 weeks
Zollinger-Ellison Syndrome 20-120mg OD
Prophylaxis of acid aspiration (during anaesthesia) 40mg the preceding evening; then 40mg 2-6 hours before surgery

 

Pantoprazole

  • Tablets 20mg, 40mg

Note:

  • IV Pantoprazole is no longer cost-effective  

 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

Return to Chapter: 1. Gastro-Intestinal System

Last updated by: Dupe Fagbenro on 05-02-2019 15:56