1.3.5 Proton pump inhibitors

Prescribing Notes

• Refer to NICE clinical guideline on Dyspepsia and gastro‑oesophageal reflux disease (2014) here.
• Omeprazole capsules should be prescribed rather than tablets. Tablets are a more expensive formulation with no additional benefit.

• When initiating a PPI, the duration of treatment should be specified where possible, preferably by stating an end date or need for long term continuation of the medicine in the directions of the prescription.
• With the exception of people with Barrett’s Oesophagus, PPIs should be ‘stepped down’ to the minimum dose that maintains symptom control in suitable patients. If the need for ongoing therapy is not reviewed, patients may continue to take unnecessarily high doses of PPIs or continue treatment beyond therapeutic need and may, therefore, be at risk of adverse effects associated with long-term use (see cautions box). Refer to stepdown SOP on primary care intranet.
• Orodispersible tablets should be reserved for patients with swallowing difficulties or who require a PPI via a naso-gastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. If an orodispersible tablet is required, lansoprazole orodispersible is the preferred choice.
• PPI suspensions are very expensive and should be reserved for patients with feeding tubes at risk of blockage. If a PPI suspension is required, licensed formulations of omeprazole suspension are now available. Please refer to product SPCs for full details and instructions for use.

• Prescribing on an ‘as required’ basis should be considered for patients with intermittent symptoms. Neither lansoprazole or omeprazole are licensed for ‘as required’ use but are frequently used for this indication and there is emerging evidence on the efficacy of on-demand therapy.

• PPIs should be taken 30 to 60 minutes before food as there is better acid suppression when taken before a meal than without a meal.
• An interaction between PPIs and clopidogrel leading to reduction of antiplatelet effect has been reported, but the clinical significance is uncertain. If co-prescribing a PPI with clopidogrel is thought necessary, lansoprazole is currently preferred to omeprazole or esomeprazole – see MHRA.
• For a patient information leaflet on the review of medication for heartburn and indigestion please see here.

Cautions

• PPIs might mask the symptoms of gastric cancer. Particular care is required in patients presenting with “alarm features”. In such cases gastric malignancy should be ruled out before treatment.
• PPIs should be used with caution in the elderly as they are more susceptible to adverse effects.
• There are concerns about the long term treatment with PPIs. The MHRA has issued safety advice on the long term use of PPIs and the following adverse effects:
  • clostridium difficile infection (see also C. difficile section in antimicrobial chapter)
  • hypomagnesaemia (MHRA link)
  • bone fracture (MHRA link)
• Subacute cutaneous lupus erythematosus has been reported with PPIs (MHRA link).
• Both lansoprazole and omeprazole interact with warfarin. Caution is required with concomitant use.