1.3 Antisecretory drugs and mucosal protectants

(a) Drugs for dyspepsia and GORD

Antacids
First choice:
co–magaldrox 195/220 (Mucogel®)
Alginates
First choice:
compound alginic acid preparations (Peptac® suspension)
H2–receptor antagonists
First choice:
ranitidine
Proton pump inhibitors
First Choice:
omeprazole
orlansoprazole
Formulations/Dose
  • Mucogel® suspension sugar free, co-magaldrox 195/220 (magnesium hydroxide 195mg, dried aluminium hydroxide 220mg/5mL): 10–20mL, 20 minutes – 1 hour after meals, and at bedtime or when required.
  • Peptac® suspension (sodium alginate 250mg, sodium bicarbonate 133.5mg, calcium carbonate 80mg per 5mL): 10–20mL after meals and at bedtime.
  • ranitidine tablets 150mg, 300mg: usually up to 150mg 4 times daily or 300mg twice daily.
  • omeprazole capsules, 10mg, 20mg, 40mg: for H. pylori eradication, 20mg twice daily (with appropriate antibiotic regimen) for 7 days. For gastro-oesophageal reflux disease, usually 20mg daily for 4–6 weeks then reducing to the minimum dose which controls symptoms.
  • lansoprazole capsules 15mg, 30mg: for H. pylori eradication, 30mg twice daily (with appropriate antibiotic regimen) for 7 days. For gastro-oesophageal reflux symptoms, usually 30mg daily for 4–6 weeks then reducing to minimum dose which controls symptoms. This may include intermittent courses of 2–4 weeks.
Prescribing Notes
  • Dyspepsia denotes a symptom and not a disease. It is a short-term problem in the majority of patients.
  • Antacids should be used for mild symptoms of dyspepsia.
  • Peptac® is the most cost effective liquid compound alginic acid preparation.  For patients who prefer tablet formulation, Gaviscon® Advance can be used.
  • Liquid formulations of antacids are more effective than tablets or capsules.
  • Compound alginic acid preparations are less powerful antacids than co-magaldrox but may be more effective for heartburn.
  • Omeprazole capsules should be prescribed rather than tablets. Tablets are a more expensive formulation with no additional benefit.
  • PPIs are most effective when taken on an empty stomach, 20-30 minutes before breakfast.
  • One week’s treatment may be sufficient to determine if dyspepsia will respond and whether it is self-limiting.
  • In most patients with gastro–oesophageal reflux disease, adequate symptom control is the principal aim of treatment. A ‘step down’ approach is encouraged starting with 20mg omeprazole daily. The dose is then adjusted upwards or downwards to maintain symptom control using the lowest dose of the most cost-effective agent (antacid, H2–receptor antagonist or proton pump inhibitor). An ‘on demand’ regimen is an option.
  • Antacids should be used for 10-14 days when withdrawing PPI treatment, to help with rebound symptoms.
  • Patients with endoscopically proven severe oesophagitis or with reflux–related oesophageal strictures require long–term therapy using a minimum dose of omeprazole 20mg daily.
  • The patient should be reviewed and the diagnosis reconsidered in those who do not respond to 40mg omeprazole daily within a 2-4 week period.
  • Esomeprazole 40mg daily may be required only on the advice of a GI consultant, for patients with endoscopically proven treatment failure of oesophagitis or those whose next treatment option is surgery.
  • Lansoprazole orodispersible tablets (Zoton FasTab®) should be reserved for patients with swallowing difficulties or who require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. Zoton FasTab® is preferred to Losec MUPS®.
(b) Drugs for the treatment of H. pylori-associated dyspepsia

First choice: for 7 days only
omeprazole 20mg twice daily
orlansoprazole 30mg twice daily
+amoxicillin* 1g twice daily

plus
● metronidazole 400mg twice daily
(not if treated with metronidazole for any infection within the past year)
Second choice: for eradication failure for 7 days only
omeprazole 20mg twice daily
orlansoprazole 30mg twice daily

plus
● amoxicillin 1g twice daily
● clarithromycin 500mg twice daily
(not if treated with macrolide for any infection within the past year)
*Patients who are allergic to penicillin
  • First line treatment may receive tetracycline 500mg twice daily instead of amoxicillin 1g twice daily.
  • Second line treatment for eradication failure may receive metronidazole 400mg three times daily instead of amoxicillin 1g twice daily. (This regimen may also be prescribed for those patients at high risk of C Diff infection.)
Prescribing Notes
  • If first line treatment fails, move to second line.
  • If eradication failure occurs, never repeat the same treatment course. Patients who fail second line therapy should be referred for specialist advice. Levofloxacin 250mg twice daily may be used only under the recommendation of a specialist.
  • Stop proton pump inhibitors 2 weeks before, and antibiotics 4 weeks before, Helicobacter pylori faecal antigen test.
  • Symptoms may persist for some weeks. In this event, continue proton pump inhibitor therapy for up to 4 weeks.
  • Patients who are experiencing symptoms of GORD are not likely to improve with H.pylori eradication therapy.  In those with chronic GORD, however, in whom long-term PPI therapy is anticipated, H. pylori eradication is recommended.
(c) NSAID–associated ulcers and dyspepsia

First choice:
omeprazole
orlansoprazole  
Formulations/Dose
  • omeprazole capsules, 20mg: NSAID-associated ulcers and gastroduodenal erosions, 20mg daily for 4–8 weeks; prophylaxis in all patients prescribed NSAID therapy, 20mg daily.
  • lansoprazole capsules 30mg: NSAID–associated benign gastric and duodenal ulcers and relief of symptoms, 15–30mg daily for 4–8 weeks (or for gastric ulcers, until healed); prophylaxis of NSAID–associated benign gastric ulcers, duodenal ulcers and symptoms, 15–30mg daily.
Prescribing Notes
  • Also refer to LJF Section 10.1.1 NSAIDs.
  • Omeprazole capsules should be prescribed rather than tablets. Tablets are a more expensive formulation with no additional benefit.
  • If NSAID-induced gastro-intestinal bleeding or ulceration occur, the NSAID should ideally be stopped, and omeprazole or lansoprazole prescribed.
  • Lansoprazole orodispersible tablets (Zoton FasTab®) should be reserved for patients with swallowing difficulties or who require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. Zoton FasTab® is preferred to Losec MUPS®.
  • Patients receiving low dose aspirin 75mg daily, who are at risk of NSAID-associated ulcers, should be prescribed a proton pump inhibitor concomitantly instead of replacing aspirin with clopidogrel.

Older Patients – Proton Pump Inhibitors

PPIs should be used with caution in the elderly.
There may be an association between PPI use and Clostridium difficile infection and osteoporosis.
Careful consideration should be made to the risk benefit ratio.
(d) Acute upper gastrointestinal bleeding
  • Refer to SIGN No. 105 Management of acute upper and lower gastrointestinal bleeding
  • PPIs should not be used - prior to diagnosis by endoscopy - in patients presenting with upper gastrointestinal bleeding.
  • Patients at high risk of re-bleeding receive endoscopic therapy to achieve haemostasis. In these patients with stigmata of recent haemorrhage, high dose intravenous PPI (esomeprazole) should be used, 80mg bolus followed by 8mg/hour infusion for 72 hours.
  • Following high dose intravenous PPI infusion, patients should be switched to oral lansoprazole or omeprazole.
  • In other ulcer patients an oral PPI should be initiated, to start the ulcer healing process. There is no need for IV PPI use in this patient group.
  • Other regular use of intravenous PPIs is not indicated, i.e. patients that are nil by mouth.