Proton Pump Inhibitors

Indication	Details
Non-ulcer dyspepsia	Short-term trial: 1 in 10 may benefit symptomatically. Lansoprazole 30mg once daily for 4 weeks. Stop if ineffective. Trial reduction if effective.
Gastro-oesophageal Reflux symptoms not controlled by alternative therapies	Symptomatic e.g. heartburn, retrosternal discomfort, acid reflux, food regurgitation (with no other proven pathology) Short-term healing dose treatment Lansoprazole 30mg once daily for 4 weeks then *step down regimen.
Endoscopically proven GORD disease (not meeting severity criteria)	Healing dose of lansoprazole 30mg once daily. Review after 4 weeks, and then *step down to maintenance treatment if possible If initial treatment fails - Lansoprazole 30mg twice daily or switch to another PPI at full or high dose followed by long term maintenance - Lansoprazole 30mg once daily
Severe oesophagitis, oesophageal ulcer, stricture or haemorrhage, Barrett's oesophagus	Lansoprazole 30mg once daily for 8 weeks, but do not step down. Refer to Gastroenterologist. If initial treatment fails - Lansoprazole 30mg twice daily or switch to another PPI at full or high dose followed by long term maintenance - Lansoprazole 30mg once daily
Gastric ulcer (GU) or duodenal ulcer (DU) Helicobacter pylori-positive	Prescribe Helicobacter pylori eradication regimen. See 'Guidelines on the Eradication of Helicobacter Pylori in Adult Patients' Full guidance available at http://nuhnet/diagnostics_clinical_support/antibiotics/Pages/Bugs/helicobacter.aspx If treatment fails refer to the antibiotic website for second line therapy (see link above).
GU or DU associated with Aspirin / NSAID use	Stop NSAID or use alternative wherever possible. Clopidogrel is not ulcerogenic. N.B. It is usually not appropriate to stop Aspirin for >3 days when given for cardiovascular prophylaxis Treat Helicobacter pylori if present Healing dose PPI - Lansoprazole 30mg once daily. Review after 8 weeks. If NSAID to restart or continue - reduce the dose of PPI once ulcer healed to lansoprazole 15mg once daily, where possible.
Gastric ulcer (GU) or duodenal ulcer (DU) Helicobacter pylori negative and not taking NSAIDs	c) Lansoprazole 30mg once daily for 4-8 weeks and refer to a gastroenterologist. ? All gastric ulcers should have endoscopic confirmation of healing unless contra-indicated. This is to identify malignancy. ? Repeat endoscopy in 6-8 weeks.
Clopidogrel and PPI's	As a precaution, concomitant use of Omeprazole or esOmeprazole should be discouraged. The evidence is unclear but manufacturers advise that concomitant use of Omeprazole or esOmeprazole and clopidogrel should be avoided where possible. It is advisable to change omeprazole/esOmeprazole to either lansoprazole, an H2 antagonist or antacids as appropriate.
PPIs and C.difficile	There is increasing evidence to support the possible link between the acid-suppressing medication (particularly PPIs) and C.difficile. Patients who are C.difficile PCR or toxin positive who are currently prescribed a PPI should have this reviewed to determine if it is still clinically justified. PPIs should be stopped or switched to ranitidine unless there is a strong clinical indication to continue them.
Need PPI and No oral access	Ranitidine IV 50mg three times a day should be considered in patients already on an oral PPI / H2 antagonist if appropriate. Omeprazole IV 40mg once daily may be used in patients who require a PPI but do not have any oral access.
Need PPI and NOT strictly Nil by Mouth	Consider: Lansoprazole oro-dispersible 15mg or 30mg once daily to dissolve on the tongue if appropriate. Lansoprazole oro-dispersible may be given via a large-bore enteral tube but ensure to flush well.