Dyspepsia

Prescribing Notes:

• Antacids should be used for mild short-term symptoms of dyspepsia.
• Peptac is the most cost effective liquid compound alginic acid preparation. For patients who prefer tablet formulation, Gaviscon Advance can be used.
• Liquid formulations of antacids are more effective than tablets or capsules.
• Compound alginic acid preparations are less powerful antacids than co-magaldrox but may be more effective for heartburn.
• PPIs are most effective when taken on an empty stomach, 20-30 minutes before breakfast.
• One week’s treatment may be sufficient to determine if dyspepsia will respond and whether it is self-limiting.
• Antacids should be used for 10-14 days when withdrawing PPI treatment, to help with rebound symptoms.
• Lansoprazole orodispersible tablets should be reserved for patients with swallowing difficulties or who require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. Lansoprazole orodispersible tablets are preferred to omeprazole dispersible tablets.
• PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridium difficile infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
• Lifestyle changes are often required, such as raising the head of the bed, weight reduction, reduction of alcohol, smoking cessation and avoidance of aggravating foods.
• Antacids, taken at the same time as other drugs, may impair their absorption. They may also damage enteric coatings designed to prevent irritant drugs from dissolving in the stomach.

Prescribing Notes:

• If first line antibiotic treatment fails, move to second line.
• If eradication failure occurs, never repeat the same treatment course. Patients who fail second line therapy should be referred for specialist advice (gastro-intestinal medicine). Amoxicillin, clarithromycin, metronidazole, or tetracycline are options, refer to BNF treatment summaries helicobacter-pylori infection. Tetracycline 500mg four times daily may be used only under the recommendation of a specialist.
• If a course of clarithromycin or metronidazole has been taken in the last year for any infection, that antibiotic should not be used in the eradication regime.
• Stop proton pump inhibitors 2 weeks before and antibiotics 4 weeks before Helicobacter pylori faecal antigen test.
• Symptoms may persist for some weeks. In this event, continue proton pump inhibitor therapy for up to 4 weeks.
• Patients who are experiencing symptoms of GORD are not likely to improve with H. pylori eradication therapy. In those with chronic GORD, however, in whom long-term PPI therapy is anticipated, H. pylori eradication is recommended.
• PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridium difficile infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
• In the absence of alarm symptoms, current practice is to treat empirically or ‘test and treat’ all patients with suspected GORD or peptic ulcer disease.

Prescribing Notes:

• If NSAID-induced gastro-intestinal bleeding or ulceration occurs the NSAID should ideally be stopped, and omeprazole or lansoprazole prescribed.
• Lansoprazole orodispersible tablets should be reserved for patients with swallowing difficulties or who require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. Lansoprazole orodispersible tablets are preferred to omeprazole dispersible tablets.
• Patients receiving low dose aspirin 75mg daily, who are at risk if NSAID-associated ulcers, should be prescribed a proton pump inhibitor concomitantly instead of replacing aspirin with clopidogrel.
• PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridium difficile infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
• Step down treatment from 20mg omeprazole daily (or equivalent), or "on demand treatment" may be appropriate when symptoms are controlled
• Stepping down treatment is NOT appropriate for the following groups:
  • people with complicated oesophagitis (LA Grade C & D)
  • people taking PPI for gastroprotection against NSAID
  • those with a previous bleeding peptic ulcer, remaining H. pylori positive after at least 2 eradication attempts
• Patients on long-term dyspepsia treatment should have six monthly reviews
• Patients should have: 2 weeks off PPI and 4 weeks off antibiotics prior to H. pylori faecal antigen test or breath test; Antacids/alginates are the preferred treatment during this period; Patients on PPIs are encouraged to increase their intake of dietary calcium.

Prescribing Notes:

• General notes on prescribing in pregnancy are available in the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.

Prescribing Notes:

• Refer to the ESPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents.
• When specialist advice is required in NHS Lothian contact paediatric gastroenterology; in NHS Fife and NHS Borders contact a paediatrician with GI interest.
• Choice of antibiotic must take into account any drug allergy/sensitivity issues.
• If a course of clarithromycin or metronidazole has been taken in the last year for any infection, that antibiotic should not be used in the eradication regime. Seek specialist advice on antibiotic choices if allergies, or prior antibiotic use mean that alternative antibiotics need to be considered. In NHS Lothian contact paediatric gastroenterology; in NHS Fife and NHS Borders contact a paediatrician with GI interest.
• Patients who are experiencing symptoms of GORD are not likely to improve with H. pylori eradication therapy. In those with chronic GORD, however, in whom long-term PPI therapy is anticipated, H. pylori eradication is recommended.
• H. pylori testing is not routinely recommended in children. However, if there is a history suggestive of dyspepsia, or other symptoms as detailed in the Paediatric GI RefHelp advice on helicobacter, then H. pylori should be tested for with faecal antigen.
• Whatever the reason for testing a positive antigen test warrants eradication therapy.
• Where antigen testing is considered, a patient must be off a proton-pump inhibitor (PPI) for 2 weeks and antibiotics for 4 weeks prior to testing.
• Symptoms may persist for several weeks even if eradication is successful. NHS Lothian paediatric GI specialists advise routinely continuing the PPI for a further 6 weeks after the initial 14 days.
• Eradication must be confirmed in children by routinely re-checking the antigen test after the course of treatment is finished even if asymptomatic.
• If eradication therapy is successful but symptoms persist, see RefHelp guidance for advice (Lothian patients).
• If re-treatment is required, see Paediatric GI RefHelp advice and discuss treatment with the paediatric GI service (Lothian patients).
• Omeprazole dispersible tablets can be dispersed in a small amount of water for 5-10 minutes and mixed well before administration. The 10mg tablets may be halved to give 5mg but must not be divided further. Proportionate doses CANNOT be administered accurately using the dispersion therefore any doses must be rounded to the nearest 5mg.
• More information on choice of PPI for administration via enteral feeding tubes and alternative PPIs can be found in the NSAID-associated ulcers and dyspepsia pathway.
• Additional information on paediatric GI conditions and initial management are available on the NHS Lothian RefHelp website. These are developed by the RHCYP Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) service, providing specialist services for Lothian, Fife and the Borders as part of the South-East Scotland Regional PGHAN Network (SESPGHAN).

Prescribing Notes:

• If NSAID-induced gastro-intestinal bleeding or ulceration occurs the NSAID should ideally be stopped, and a PPI prescribed.
• It may be appropriate to step down to a lower maintenance dose, or give "on demand treatment" when symptoms are controlled.
• Patients receiving low dose aspirin, who are at risk if NSAID-associated ulcers, should be prescribed a proton pump inhibitor concomitantly instead of replacing aspirin with clopidogrel.
• Stepping down treatment is NOT appropriate for the following groups:
  
  • people with complicated oesophagitis
  • people taking PPI for gastroprotection against NSAID
  • those with a previous bleeding peptic ulcer, remaining H. pylori positive after at least 2 eradication attempts
• Patients on long-term dyspepsia treatment should have six monthly reviews.
• Where antigen testing is considered, a patient must be off a proton-pump inhibitor (PPI) for 2 weeks and antibiotics for 4 weeks prior to testing.
• Antacids/alginates are the preferred treatment during this period; Patients on PPIs are encouraged to increase their intake of dietary calcium.
• Omeprazole dispersible tablets can be dispersed in a small amount of water for 5-10 minutes and mixed well before administration. The 10mg tablets may be halved to give 5mg but must not be divided further. Proportionate doses CANNOT be administered accurately using the dispersion therefore any doses must be rounded to the nearest 5mg.
• Omeprazole dispersible tablets are suitable for patients with swallowing difficulties or who require a proton pump inhibitor via large bore feeding tubes, providing the tube is flushed well before and after administration. Omeprazole tablets tend to block fine bore enteral feeding tubes and should not be used for this patient group.
• There are a variety of omeprazole liquid formulations, these are not approved for use in East region. The cost of these formulations is substantially more than the tablets or capsules. Where a liquid PPI formulation is requested for patients who have tried the omeprazole dispersible tablets orally, provide guidance on correct administration technique. If problems persist, consider alternative formulary options such as lansoprazole orodispersible tablets or esomeprazole granules.
• Lansoprazole orodispersible tablets should be reserved for patients with swallowing difficulties or who require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube.
• If alternative PPI formulations are blocking a wide bore nasogastric/gastrostomy feeding tube despite correct administration technique or when the patient has a narrow bore enteral feeding tube (i.e. jejunal), esomeprazole granules are an option. For patients less than 1 year see dose recommendations for esomeprazole in the GORD pathway.
• Additional information on paediatric GI conditions and initial management are available on the NHS Lothian RefHelp website. These are developed by the RHCYP Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) service, providing specialist services for Lothian, Fife and the Borders as part of the South-East Scotland Regional PGHAN Network (SESPGHAN).

Prescribing Notes:

• Liquid formulations of antacids are more effective than tablets or capsules.
• Peptac is the most cost effective liquid compound alginic acid preparation.
• Proton Pump Inhibitors are not included in the approved list– they could be purchased but consideration should be given to referring the patient to their GP if symptoms not alleviated by the approved list first choices.
• NICE CG184 - Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management.
• NICE Guideline 1 - Gastro-oesophageal reflux disease in children and young people: diagnosis and management.
• Lifestyle advice should be provided, e.g encouraging weight loss, smoking cessation, reducing alcohol intake.

Example of counselling points
Avoid large meals, eat little and often.
Do not rush your food.
Avoid spicy and greasy foods as they can often worsen heartburn.
Some heartburn remedies can stop other medicines from working. Check if the heartburn remedy would interfere with other medicines.

When to advise patient to contact GP
Child under 2 years.
Difficulty swallowing.
Symptoms are persistent (longer than 5 days) or recurrent.
Pain is severe or radiating.
Blood in vomit or stools.
Pain worsens on effort.
Persistent vomiting.
Adverse drug reaction is suspected.
Associated weight loss.
First episode at age over 40.