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BNSSG Adult Joint Formulary

1.4 Disorders of gastric acid and ulceration

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Last edited: 28-03-2024

1.4.1 Dyspepsia

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

NICE guidance CG 184 Dyspepsia and gastro-oesophageal reflux disease: Investigation and management of dyspepsia

Alginates

Recommended: (TLS Green)

Peptac^® Liquid

Peptac^® liquid is sugar-free but contains 3.1mmol sodium per 5mL

Antacids

Alternatives: (TLS Blue)

Co-magaldrox 195/220 suspension (Mucogel^® - low in sodium)

Specific indication: (TLS Blue)

Sodium citrate

Prophylaxis of acid aspiration

1.4.2 Gastric and duodenal ulceration

Peptic Ulceration

Helicobacter pylori Infection

Recommended:

Omeprazole 20mg bd, Amoxicillin 1g bd and Clarithromycin 500mg bd for 1 week (TLS Green)

If the patient is penicillin allergic:

Omeprazole 20mg bd, Metronidazole 400mg bd and Clarithromycin 500mg bd for 1 week (TLS Blue)

Statins which are extensively metabolised by the CYP3A4 enzyme such as atorvastatin, pravastatin and simvastatin should be stopped for the duration of the eradication, due to interaction
Following eradication of H. pylori associated with duodenal ulcers uncomplicated by haemorrhage or perforation, 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.
See local guidance for alternative regimens.

Chelates and Complexes

Specific indication: (TLS Blue)

Sucralfate (oral) (unlicensed)

Existing patients only
Joint Formulary decision: No new patients are to be initiated on Sucralfate

Sucralfate 2g/50mL enema (TLS Amber Specialist Recommended)

Sucralfate 3g/20mL enema (TLS Red)

Specific indication:

Bismuth chelate (TLS Amber Specialist Recommended)

Third line option on recommendation of specialist for H.pylori eradication as per Public Health England

Proton Pump Inhibitors

NICE clinical guideline 184 states that the lowest effective dose and frequency should be used.
MHRA warning on increased risk of fractures and hypomagnesaemia
See BNSSG Guidelines on Optimising and reviewing Proton Pump Inhibitors (PPI) April 2022

Omeprazole capsules & intravenous infusion (TLS Green)

Omeprazole oral suspension is non-formulary for adults.

Lansoprazole capsules (TLS Green)

Specific indications: (TLS Blue)

Omeprazole dispersible gastro-resistant tablets

For patients with swallowing difficulties

Lansoprazole fastabs

For patients with swallowing difficulties or for administration via PEG/NG

Esomeprazole tablets/capsules

Endoscopically proven high grade oesophagitis
Laryngeal reflux
Patients with reflux associated cough who have not responded to omeprazole
Patients who have not responded to two high dose PPI one month trials i.e. Lansoprazole 30mg od, omeprazole 40mg od

Esomeprazole granules

For patients with swallowing difficulties or requiring administration via PEG/NG

Pantoprazole (intravenous)

For use in critical care and Home Parenteral Nutrition
Ensure that the reason for initiation with a PPI and length of treatment are stated on the discharge prescription from hospital.
Patients requiring maintenance doses of PPI should continue on the lowest dose and lowest frequency that keeps symptoms under control

H₂-Receptor Antagonists

NICE CG184 'Dyspepsia and gastro-oesophageal reflux disease: Investigation and management of dyspepsia

Famotidine (TLS Green)

where a PPI is not appropriate or unless specialist recommended

Nizatidine (TLS Green)

where a PPI is not appropriate or unless specialist recommended

Cimetidine (TLS Blue) - for use in Meckel's scans

Eosinophilic Oesophagitis

Budesonide orodispersible tablets (TLS Red)

For inducing remission of eosinophilic oesophagitis with treatment of up to 12 weeks in line with NICE TA708

Budesonide orodispersible tablets (TLS Amber 3 months)

For maintenance treatment of eosinophilic oesophagitis. See SCP and Pathway

Acetic acid solution (TLS Red)

For use during a screening gastroscopy to enhance identification of dysplastic areas in patients with Barrett's Oesophagus

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