Proton pump inhibitors

Proton pump inhibitors may mask the symptoms of gastric cancer; particular care is required in those presenting with ‘alarm features’ and in such cases gastric malignancy should be ruled out before treatment. Patients at risk of osteoporosis should maintain an adequate intake of calcium and vitamin D, and, if necessary, receive other preventative therapy.
Rebound acid hypersecretion and protracted dyspepsia may occur after stopping prolonged treatment with a proton pump inhibitor.
In those at risk of ulceration when taking NSAIDS (over 65 and/or history of ulceration, a proton pump inhibitor can be considered for protection against gastric and duodenal ulcers associated with non-selective NSAIDs. A proton pump inhibitor should be prescribed for appropriate indications at the lowest effective dose for the shortest period; the need for long-term treatment should be reviewed periodically.
Severe hypomagnesaemia may occur in patients treated with PPIs, although the exact incidence is unknown. Where this is a clinical concern, prescribers may also decide to use a magnesium containing product such as magnesium hydroxide (not suitable for patients with short bowel syndrome) or Mucogel (see previous page)

Deprescribing guidance. Decision guides on whether PPIs can be deprescribed can be found on the medicines management website at http://www.somersetccg.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=6065 
Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Proton-pump inhibitors
NB. Refer to NICE guidance on use of PPIs
Lansoprazole capsules15mg capsules: £0.94
30mg capsules: £1.26
Only use Lansoprazole orodispersible tablets (Zoton FasTabs®) as an alternative to costly special liquid formulations.
Omeprazole capsules10mg capsules: £0.90
20mg capsules: £0.91
Only use Omeprazole dispersible tablets (Losec MUPS®) as an alternative to costly special liquid formulations and where lansoprazole orodispersible tablets are not an acceptable alternative.
As Mepradec®
or Mezzopram®
10mg capsules: £0.83
20mg capsules: £0.83
Where Omeprazole 20mg once-daily is not effective, increasing dose to 2x20mg daily (not 1x40mg) or using Lansoprazole 30mg daily is recommended.
Pantoprazole tablets20mg tablets: £0.99
40mg tablets: £1.16
Pantoprazole has been included for circumstances where a tablet formulation is necessary.
For patients currently taking Nexium® tablets who are unable to change to omeprazole, lansoprazole or pantoprazole, product should be prescribed as Ventra® capsules (esomeprazole capsules 20mg and 40mg)
Esomeprazole
as Ventra®
Capsules 20mg: £2.55
Capsules 40mg: £2.97
Helicobacter pylori eradicationPlease refer to Infection Management Guidance
First line:PPI & Amoxicillin +
either Clarithromycin
OR Metronidazole
1g BD
500mg BD
400mg BD
Treat all positives in known DU, GU or low grade MALToma. In Non-Ulcer NNT is 14.
Do not offer eradication for GORD.
First line treatment: choose the treatment regimen with the lowest acquisition cost, and take into account previous exposure to clarithromycin or metronidazole.
Do not use Clarithromycin, Metronidazole or Quinolone if used in past year for any infection.
Retest for H. pylori post DU/GU or relapse after second line therapy: using breath or stool test OR consider endoscopy for culture and susceptibility.
Seek advice from a gastroenterologist if eradication of H pylori is not successful with second-line treatment.

Always use PPI TWICE DAILY: Esomeprazole 20mg, Lansoprazole 30mg, Omeprazole 20-40mg, Pantoprazole 40mg

Duration of treatment-All for 7 days (MALToma 14 days).
Penicillin allergy
PPI & Metronidazole
& Clarithromycin
400mg bd
500mg bd
Penicillin allergy with previous exposure to Clarithromycin
>PPI & Bismuthate (De-noltab®) &
Metronidazole
& Tetracycline
240mg BD
400mg BD
500mg QDS
Second line:(Still have symptoms after 1st line eradication):
PPI & Amoxicillin +
either Clarithromycin
OR Metronidazole
(whichever was not first line)
1g BD
500mg BD
400mg BD
Previous exposure to Clarithromycin & Metronidazole
PPI & Amoxicillin +
either Tetracycline
OR Levofloxacin
1g BD
500mg QDS
250mg BD
Penicillin allergy without previous exposure to Quinolone
PPI & Metronidazole
& Levofloxacin
400mg BD
250mg BD
Penicillin allergy with previous exposure to Quinolone
PPI & Bismuthate ( De-noltab® ) &
Metronidazole
& Tetracycline
240mg BD
400mg BD
500mg QDS