Prudent Healthcare
Medicines management workshop
Proton Pump Inhibitors
1. Products
Proton pump inhibitors (PPIs) are listed in British National Formulary
(BNF) section 1.3.5. They include:
Lansoprazole (Zoton®)
Omeprazole (Losec®)
Esomeprazole (Nexium®)
Pantoprazole (Protium®)
Rabeprazole sodium (Pariet®)
Combination products are also available. These are:
Vimovo® (naproxen + esomeprazole)
Axorid® (ketoprofen + omeprazole)
(The hyperlink links to one manufacturer’s summary of product
characteristics (SPC) for one formulation/ strength of the drug. The SPCs
for alternative manufacturer’s/ formulations/ strengths can be searched
for at eMC)
2. Indications
Proton pump inhibitors inhibit gastric acid secretion. Indications vary
between products and according to dosage. The licensed indications of
PPIs include:
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Treatment of gastric and duodenal ulcers
Eradication of Helicobacter pylori
Dyspepsia
Gastro-oesophageal reflux disease
Prevention and treatment of NSAID-associated ulcers
Reduce degradation of pancreatic enzyme supplements in patients
with cystic fibrosis
Zollinger-Ellison syndrome
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“A proton pump inhibitor should be prescribed for appropriate
indications at the lowest effective dose for the shortest period; the
need for long-term treatment should be reviewed periodically” 1
3. National Institute for Health and Care Excellence (NICE)
3.1.
Clinical guidelines recommending use of PPIs
Management of dyspepsia in primary care (CG17)
Acute upper GI bleeding (CG141)
In addition, prescribing a PPI to provide gastro-intestinal protection when
prescribing other medicines e.g. NSAIDs, low dose aspirin, SSRIs, is
mentioned in a number of NICE clinical guidelines, examples include
rheumatoid arthritis (CG79), low back pain (CG88), osteoarthritis
(CG177), stroke (CG68) and depression with a chronic physical health
problem (CG91).
3.2.
Do not do recommendation
From CG141 (ID: 1078)
Do not offer acid-suppression drugs (PPIs or H2-receptor antagonists)
before endoscopy to patients with suspected non-variceal upper
gastrointestinal bleeding.
4. Medicines and healthcare products regulatory agency (MHRA)
drug safety updates
Hypomagnesaemia with long-term PPI usage
Prolonged use of PPIs has been associated with hypomagnesaemia.
Healthcare professionals should consider measuring magnesium levels
before starting PPI treatment and repeat measurements periodically
during prolonged treatment, especially in those who will take a PPI
concomitantly with digoxin or drugs that may cause hypomagnesaemia
(e.g., diuretics).
[Drug Safety Update Vol. 5, Issue 9. April 2012]
Increased risk of fracture with long term PPI usage
There is epidemiological evidence of an increased risk of fracture with
long-term use of PPIs. Patients at risk of osteoporosis should be treated
1
BNF edition 66, September 2013-March 2014, [page 55]
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according to current clinical guidelines to ensure they have an adequate
intake of vitamin D and calcium.
[Drug Safety Update Vol. 5, Issue 9: April 2012]
Interaction between clopidogrel and omeprazole/ esomeprazole
Use of either omeprazole or esomeprazole with clopidogrel should be
discouraged. The current evidence does not support extending this advice
to other PPIs.
[Drug Safety Update Vol. 3, Issue 9. April 2010]
5. Additional health issues
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Decreased gastric activity, due to any means-including PPIsincreases gastric counts of bacteria normally present in the
gastrointestinal tract. Treatment with acid reducing drugs leads to
an increased risk of gastrointestinal infections such as salmonella,
campylobacter or Clostridium difficile
FDA Drug Safety Communication 2012: Clostridium difficile and PPIs
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Potential to mask malignant gastro-intestinal disease
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PPIs may be encouraging unhealthy lifestyle choices e.g. high fat
diet, excessive alcohol consumption, over-eating, smoking, if
patients are overcoming the unpleasant GI consequences from
these behaviours by taking a PPI rather than modifying their
behaviour to avoid the symptoms
6. All Wales Prescribing Indicators
In 2011-12 there were two national prescribing indicators for PPIs. These
were:
 Defined daily doses per 1000 prescribing units
 PPI items of low acquisition cost as a percentage of all PPIs
Further information on national prescribing indicators and their analysis
from 2011-12 to 2014-15 can be found in the online AWMSG library
Cwm Taf had traditionally high rates of low acquisition cost PPI
prescribing; this has been supported by the Cwm Taf formulary
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7. Resources to support change
7.1.
All Wales Therapeutics and Toxicology Centre (AWTTC)
All Wales proton pump inhibitor and dyspepsia resource pack 2013
CEPP All Wales Audit: Reducing the use of high acquisition cost proton
pump inhibitors 2011-2013
Patient information leaflet: Proton Pump Inhibitors for the treatment of
dyspepsia and heartburn English/ Welsh
Stopping medicines- proton pump inhibitors WeMeReC e-notes 2010
7.2.
NICE shared learning database
The way to medicines optimisation is through the stomach - tackling high
prescribing levels using the NICE dyspepsia guideline to review proton
pump inhibitor (PPI) prescribing.
7.3.
Cwm Taf Health Board
The Cwm Taf Medicines Management Practice Unit works with GP
practices in Cwm Taf to encourage clinically and cost effective prescribing.
The Unit was involved in the development of the CEPP All Wales audit and
guidelines on PPI prescribing (hyperlink above). These were sent to GP
practices in Cwm Taf. A PowerPoint presentation on dyspepsia
management was also made available to practices. A multidisciplinary
audit pack was developed for use by community pharmacy and formed
part of the community pharmacy contractual requirement in Cwm Taf for
2011/12 (attachment 1). Despite this work the total quantity of PPIs
prescribed continues to rise year on year.
Attachment 1Community Pharmacy PPI audit.doc
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