• Oral problems, such as tooth decay, gingivitis, and halitosis3


.


Treatment NICE recommends a full-dose proton pump inhibitor (PPI) for one month as first line treatment for endoscopically proven oesophagitis and endoscopy- negative reflux disease3


.


It is well-recognised that PPIs are more effective than other drugs, such as antacids and prokinetics, at treating symptoms of GORD.


Evidence has shown that PPIs are significantly more effective than placebo and histamine (H2) receptor antagonists at treating oesophagitis3


.


Co-medication with an agent that requires gastroprotection, such as NSAIDs or corticosteroids, is one example. Illnesses such as Zollinger- Ellison syndrome, Barretts oesophagus and severe oesophagitis also require co-administration with a PPI.


Patients with a history of ulcer complications, such as perforation or bleeding, require a PPI long term1


.


It is important that patients are encouraged to undergo a trial of stepping down or stopping PPI treatment, unless they have a reason to remain on long term treatment as discussed above1


. .


PPIs are also more effective at treating endoscopy-negative reflux disease3


In 2013, 12% of the population of Northern Ireland received a PPI and PPI prescribing continues to increase1


.


Studies have shown that the number of patients receiving PPI treatment exceeds the prevalence of diseases which PPIs are indicated for.


In fact, despite esomeprazole being hugely popular, it should not be prescribed in primary care. If it is started following a Gastroenterology/ Upper GI/ Surgical specialist appointment, the choice and duration of esomeprazole treatment should not be altered1


.


Of the five PPIs currently available within the UK, omeprazole, lansoprazole and pantoprazole are the most cost-effective.


Although all PPIs have been studied for their effectiveness in on-demand recurrent dyspepsia, only rabeprazole and esomeprazole are licensed for this indication.


If a patient reports failure of a PPI, it is advised that pharmacists enquire about patient compliance.


As many as 90% of patients with GORD experience nocturnal acid breakthrough. Adding a histamine 2 receptor antagonist (H2RA) can help to alleviate this problem in the short term.


Unfortunately, after one or two weeks of this dual therapy, most patients find a decline in symptom control as the benefits of the H2RA add-on treatment are short-lived1


.


There are many reasons for a patient to remain on PPI treatment long-term.


Proton Pump Inhibtor Omeprazole Lansoprazole Rabeprazole Pantoprazole Esomeprazole


Full dose


20mg once daily 30mg once daily 20mg once daily 40mg once daily 20mg once daily


Patients should be advised to use the lowest effective dose of their PPI, using it on an “as-needed” basis where appropriate, before returning to self-treatment with alginates and/ or antacid therapies1


.


Safety concerns with the long term use of PPI’s Although there are few occurrences of side effects with the short term usage of PPIs, it has recently been discovered that uncommon side effects are linked with long term usage.


These include vitamin B12 deficiency, hypomagnesaemia, osteoporotic fracture, C. Difficile infection and pneumonia1


.


It is thought that the reduction in stomach acid secretion caused by PPI administration results in reduced uptake of vitamins and minerals.


Hypomagnesaemia has been a reported side effect of long term PPI usage in patients, most of whom were treated with PPIs for over a year, although some had just three months of treatment1


.


In light of this, the MHRA has advised that patients should have their magnesium levels measured prior to the initiation of a PPI and should undergo regular checks throughout.


Pharmacists are in a prime position to be alert for patients who receive digoxin and other diuretics; these patients should have their magnesium levels checked if they have received six months of treatment or more1


.


There is a moderately increased risk of hip, wrist or spine fracture, particularly in patients who have been taking PPIs for over a year and also if the dose is high1


.


Reduced (On-demand) Dose 10mg once daily* 15mg once daily 10mg once daily 20mg once daily Not Available


Table 2 lists the full and reduced dosages of proton pump inhibitors1 *This dose is off-label for GORD treatment


pharmacyinfocus.co.uk 19


There are guidelines in place to ensure that any patient at risk of osteoporotic fracture receives a suitable intake of vitamin D and calcium.


C. difficile associated diarrhoea is two to three times more likely in patients receiving a PPI. Any patient at risk of C. Difficile infection should have their PPI held during any treatment with a broad-spectrum antibiotic.


After C. Difficile infection, the patient should be advised to stop their PPI. However, if it is re-started, any future antibiotic treatment will necessitate the halt of PPI treatment1


.


Another safety concern of PPIs is the link they have with interstitial nephritis. They have been recognised as an underappreciated cause of acute kidney injury.


All newly prescribed PPIs should be reviewed after four weeks, and annual review should be offered to all patients with conditions which require long term management with a PPI4.


Laparoscopic fundoplication is a surgical procedure which can be considered for patients who either respond to acid suppression therapy but refuse to take long term therapy, or have been diagnosed with acid reflux but cannot tolerate acid suppression therapy1


.


It is a procedure which involves wrapping the top portion of the stomach to the bottom of the oesophagus, creating a tighter sphincter. n


References Bradley, M. COMPASS Therapeutic Notes on the Management of Upper Gastrointestinal disorders. 2015. Available at: https://www.nicpld.org/courses/COMPASS/mana gementOfUpperGIDisorders.pdf [Accessed 7/10/15]


NHS Choices, 2014. Causes of gastro- oesophageal reflux disease. Available at: http://www.nhs.uk/Conditions/Gastroesophagea l-reflux-disease/Pages/Causes.aspx [Accessed 6/10/15]


NICE CKS. Dyspepsia – Proven GORD – Summary. 2012. Available at : http://cks.nice.org.uk/dyspepsia-proven- gord#!topicsummary [Accessed 7/10/15] Antoniou T et al. Proton Pump Inhibitors and the risk of acute kidney injury in older patients: a population study. CMAJOPEN. 2015. Available at: http://www.cmajopen.ca/content/ 3/2/E166.short [Accessed 10/10/15]


Double dose


40mg once daily 30mg twice daily* 20mg twice daily* 40mg twice daily* 40mg once daily


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