PROTON PUMP INHIBITORS KEY POINTS
NICE guidance recommends the use of the lowest dose providing effective symptom relief of the
lowest priced PPI for licensed indications. On demand use of PPIs is encouraged if patients need
long-term management.
Discuss lifestyle issues with patients, reduce weight, stop smoking, reduce alcohol, avoid foods
that aggravate symptoms.
Stepping Hill Hospital consultants use lansoprazole capsules as their PPI of choice.
There is no reason to use esomeprazole in preference to any of the other PPIs.
Current costs for PPIs
Cost per 28 days (4/2010)
Lansoprazole 30mg caps
Lansoprazole 15mg caps
Omeprazole 20mg caps
Esomeprazole 40mg tabs
Esomeprazole 20mg tabs
Lansoprazole 30mg orodispersible (Zoton fastabs)
Omeprazole 20mg dispersible tabs (Losec Mups)
Omeprazole 20mg tabs
Rabebrazole 20mg tabs
Pantoprazole 40mg tabs
£2.78
£1.78
£2.04
£25.19
£18.50
£5.50
£11.60
£7.56
£19.55
£4.34
Managing repeat prescribing
When a PPI is initiated in secondary care it should not be added to a patient’s repeat medication
record without review unless a clinical indication to continue has been given. When no indication
has been given the patient should be called in for review.
Don’t issue repeats for full treatment doses of PPIs. NICE guidelines recommend one to two
months treatment with a full dose PPI initially then review or step down as appropriate depending
on the circumstances.
Limit the number of repeat prescriptions available and specify review date. NICE recommends
one-month empirical treatment with a full dose PPI for patients with dyspepsia not needing
referral
Encourage the use of PPIs or H2RAs on an as-required rather than on a regular basis.
Symptoms are intermittent therefore treatment should be too. Many patients with dyspepsia
may find immediate symptom relief from antacids / alginates avoiding the need for further
medication.
There are safety concerns emerging around long term use of PPIs, including associations with
increased risks of pneumonia, Clostridium difficile diarrhoea and hip fractures.
Omeprazole 20mg and lansoprazole 15-30mg are licensed for prophylaxis to reduce risk of GI
bleed in high risk patients on long term NSAIDs.
Avoid using omeprazole and esomeprazole in patients taking clopidogrel.
ACTION PLAN FOR REDUCING COSTS OF PPIs
Action
Comment
Review patients on
esomeprazole
Try omeprazole
20mg caps instead
Review use of
orodispersible
preparations of
omeprazole and
Lansoprazole
Change to cheapest
generic form if no
swallowing
difficulties
Review patients on
twice daily doses of
PPIs
High dose PPIs
should only be used
short term, reduce
dose to once daily
or as required.
Step down to
maintenance or as
required dosing
Check at annual
review current
pattern of use and
promote using
lowest dose that
controls symptoms
Do not routinely add
full dose PPI to
repeat medication
If patients have
dyspepsia or
heartburn which
needs no
investigation, give 1
month acute supply
only
Agreement
Who
By when