Antisecretory drugs and mucosal protectants

First choice PPI: OMEPRAZOLE
First choice H2-receptor antagonist: RANITIDINE

 

Omeprazole (capsules, tablets and injection) and lansoprazole (capsules, suspension) are proton pump inhibitors (PPIs). They produce profound gastric acid suppression. They are the most effective treatment for gastro-oesophageal reflux disease. They are effective short-term treatments for gastric and duodenal ulcers.

 They may achieve a faster healing rate than H2-receptor antagonists but the relapse rate is similar. PPIs are also used in combination with antibacterials for Helicobacter pylori eradication.

High doses of PPIs are only indicated in the initial healing phase of severe erosive oesophagitis or peptic ulcer, for an initial period of 4 weeks or so, after which dosage can usually be reduced.



Maintenance doses with PPIs are only indicated in erosive ulcerating or stricturing oesophagitis and occasionally in the prophylaxis of NSAID peptic ulceration. Every effort should be made to reduce the dose of PPIs to the lowest effective maintenance dose after the initial "healing" period. See local information on PPI prescribing.

Ranitidine (tablets, dispersible tablets, syrup, injection) is suggested as the first choice H₂-receptor antagonist in most patients. It has fewer side-effects than cimetidine and is less likely to cause interactions with other drugs. It can be used in patients with renal or hepatic impairment, concurrent multiple therapy and those on high doses for hypersecretory states. Ranitidine is the recommended injectable H2-receptor antagonist.

Cimetidine (tablets, syrup) is effective in treating gastric and duodenal ulcers and will also relieve peptic oesophagitis. It inhibits drug metabolism and so should be avoided in patients stabilised on warfarin, phenytoin, theophylline and aminophylline.  See BNF for full list of interactions.
 

SPECIAL INDICATIONS

Misoprostol (tablets) can protect against NSAID-associated gastric and duodenal ulcers in patients with a previous history of peptic ulcers in whom the use of NSAIDs is absolutely essential. It should not be routinely prescribed with NSAIDs. Side-effects are common. It should not be used in women who are pregnant or planning pregnancy because it increases uterine tone.Sucralfate (tablets, suspension) has a direct protective effect on the mucosa. It is mainly used in ITU and in patients undergoing radiotherapy to the mouth and throat. Caution should be used in seriously ill patients due to reports of bezoar formation.

Tripotassium dicitratobismuthate (tablets, proprietary name De-Nol®) is effective in healing gastric and duodenal ulcers. It is used in Helicobacter pylori eradication in patients who have not responded to first-line eradication regimens. See BNF for details.

HELICOBACTER PYLORI ERADICATION THERAPY

Almost all duodenal ulcers which are not caused by NSAIDs are caused by Helicobacter pylori. Eradication using one of the following regimens is recommended. The management of gastric ulcers should be carried out by specialists due to the need for repeated endoscopy to confirm healing.

Table 1: Recommended regimens for Helicobacter pylori eradication

TREATMENT to continue for 7 days
ACID SUPPRESSANT	ANTIBIOTIC
	AMOXICILLIN	CLARITHROMYCIN	METRONIDAZOLE
Omeprazole 20mg twice daily	1gm twice daily	500mg twice daily	----------
	500mg three times daily	----------	400mg three times daily
	----------	250mg twice daily	400mg twice daily
Lansoprazole 30mg twice daily	1gm twice daily	500mg twice daily	----------
	1gm twice daily	----------	400mg twice daily
	----------	250mg twice daily	400mg twice daily

PRESCRIBING POINTS FOR HELICOBACTER PYLORI AND PEPTIC ULCER

• It is recommended that H. pylori is confirmed before starting treatment.
• Patients should be aware that compliance is essential for an effective outcome. They should be warned of potential side-effects. Symptoms do not settle immediately even after successful therapy.
• To aid compliance HeliClear® (containing lansoprazole 30mg, clarithromycin 500mg and amoxicillin 500mg) is available.
• Confirmation of eradication with a carbon isotope urea breath test requires stopping treatment with proton pump inhibitors two weeks prior to testing. H2-receptor antagonists are used sometimes to reduce the painful gastric symptoms experienced by patients who must stop PPIs prior to the urea breath test. Patients are often requested to stop taking H2-receptor antagonists for 12 to 24 hours prior to the urea breath test to ensure they do not interfere with the test.
• In cases of complicated peptic ulcer i.e. patients with haemorrhage or perforation - maintenance therapy should only be discontinued once eradication of H. pylori has been confirmed by a carbon isotope urea breath test six weeks after therapy.
• Traditional triple therapy (two-week regime) using tripotassium dicitratobismuthate plus a proton pump inhibitor plus two antibacterials may have a role in the treatment of resistant cases.
• Two-week dual-therapy regimens are not recommended.

PAEDIATRIC NOTES - ULCER-HEALING DRUGS

Ulcer-healing drugs should not be used in children without prior specialist investigation.
Cimetidine and oral ranitidine are licensed for use in paediatrics.
Ranitidine injection [unlicensed] is used at a dose of 1mg/kg three times a day.
Omeprazole is licensed in children over two years with severe ulcerating reflux oesophagitis. It is used in children for peptic ulcers refractory to H2-receptor antagonists [unlicensed use]. It is available as a dispersible tablet.

Helicobacter pylori - treatment should continue for 1 week.
Over 14 years -Treatment as for adults 12-14 years - Omeprazole 20mg daily + antibiotics as for adults
5-12 years - Omeprazole 10mg daily + clarithromycin 250mg twice a day + amoxicillin 250mg three times a day OR metronidazole 200mg three times a day.

GERIATRIC NOTES - ULCER-HEALING DRUGS

Ranitidine is of special value in the elderly (who are more likely to have renal or hepatic impairment and be on multiple therapy) because it has fewer side-effects and is less likely to cause drug interactions. The use of a proton pump inhibitor should be considered in elderly patients taking NSAIDs.
Treatment of undiagnosed dyspepsia in elderly patients is undesirable because of the risk of delaying diagnosis of cancer.  
Esomeprazole (10mg gastro-resistant granules for oral solution, sachet Nexium®) is restricted to use by the paediatric service for children (1 to 11 years old) who have nasogastric/PEG tubes and are unable to take medicines orally.