Gastro-oesophageal reflux disease (GORD)

Prescribing Notes:

• 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.
• Omeprazole capsules should be prescribed rather than tablets. Tablets are a more expensive formulation with no additional benefit.
• PPIs are most effective when taken on an empty stomach, 20-30 minutes before breakfast.
• In most patients with gastro-oesophageal reflux disease, adequate symptom control is the principal aim of treatment. A ‘step down’ approach is encouraged starting with 20mg omeprazole daily or 30mg lansoprazole daily. The dose is then adjusted upwards or downwards to maintain symptom control using the lowest dose of the most cost-effective agent (antacid, H2-receptor antagonist or proton pump inhibitor). An ‘on demand’ regimen is an option.
• Patients with endoscopically proven severe oesophagitis or with reflux-related oesophageal strictures require long-term therapy using a minimum dose of omeprazole 20mg daily or 30mg lansoprazole daily.
• The patient should be reviewed and the diagnosis reconsidered in those who do not respond to 40mg omeprazole daily within a 2-4 week period.
• 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.

Prescribing Notes:

• PPIs should ideally not be used - prior to diagnosis by endoscopy - in patients presenting with upper gastrointestinal bleeding.
• Following high dose intravenous PPI infusion, patients should be switched to oral lansoprazole or omeprazole.
• In other ulcer patients an oral PPI should be initiated, to start the ulcer healing process. There is no need for IV PPI use in this patient group.
• Other regular use of intravenous PPIs is not indicated, i.e. patients that are nil by mouth.
• Choice of PPI should reflect local guidance.

Prescribing Notes:

General notes

• GORD may be more difficult to diagnose in children than in adults. A therapeutic trial of omeprazole for 6 weeks is reasonable.
• In most patients with symptomatic severe gastro-oesophageal reflux disease, adequate symptom control is the principal aim of treatment. A ‘step down’ approach is encouraged starting with omeprazole for severe symptoms and stepping down antacid for more prolonged treatment. An ‘on demand’ regimen is acceptable providing it is effective.
• If diagnosis is unclear or symptoms are not severe, a ‘step up’ approach should be taken.
• Patients who are being tube fed should have omeprazole or an H2 antagonist for 6 weeks and then review of ongoing treatment.
• 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).

Alginates, antacids and thickeners

• The common indication for antacids and alginates is for gastro-oesophageal reflux.
• Peptac suspension is equivalent to Gaviscon liquid.
• Feed thickeners or anti-reflux milks can be effective for simple reflux occurring in bottle fed infants.
• Compound alginic acid preparations should not be given with thickeners or anti-reflux milks.
• Anti-reflux milks are not effective if used with acid suppression.
• Each half of the Gaviscon Infant dual sachets is one dose. To avoid errors, prescribe with directions in terms of ‘dose’ not ‘half a sachet’.
• Alginates are predominantly for protection of oesophageal mucosa; they don’t have an antacid effect.
• Antacids may be appropriate first step for dyspepsia in older children.

H2 antagonists

• For further out of stock information on H2-anatagonists please see the national MSAN (Ranitidine: all formulations) and national MSAN (H2-anatagonists). All forms of ranitidine are currently out of stock with no date of recovery.

Proton pump inhibitors

• PPIs are most effective when taken on an empty stomach, 20-30 minutes before breakfast.
• 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 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 recommended.
• When stepping down treatment from a PPI, dose reduction alone may be all that is required, or the introduction of an H2 antagonist then dose reduction of the PPI may be needed.
• Specialists may recommend high dose PPI in selected cases, omeprazole is the recommended PPI for high dose treatment.

Domperidone

• The MHRA have highlighted that domperidone may prolong the QT interval in adults, although no current evidence exists in children. Caution should be exercised in the co-prescribing of medicines which are known to prolong the QT interval. Key elements of the MHRA advice is domperidone should be used at the lowest effective dose for the shortest possible time. MHRA advice also notes that due to no evidence of benefit over placebo, domperidone is no longer licensed in under 12 years of age.
• Patients currently receiving long term treatment with domperidone should be reassessed at a routine appointment to advise on treatment continuation, dose change or stopping treatment. See flow chart for further guidance.

Prescribing Notes:

• PPIs should be used in parallel with endoscopy planning in patients presenting with upper gastrointestinal bleeding.
• The most appropriate route of administration should reflect the acuity of the clinical problem, for example Suitable for Oral vs IV.
• If urgent endoscopy is not possible, do not delay PPI administration and early discussion with the RHCYP GI team is encouraged.
• Following high dose intravenous PPI infusion, patients should be switched to an oral PPI and stopped when appropriate.
• Refer to the NHS Lothian Paediatric Upper Gastrointestinal Bleeding Guideline.
• Refer to Oesophageal varices section of UGI guidance for management of bleeding oesophageal varices with octreotide.

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.