page75
ulcer
has healed,
the dose of
proton pump inhibitor
should normally not be reduced because asymptomatic
ulcer deterioration may occur.
A proton pump inhibitor
can be used to reduce the
degradation of pancreatic enzyme supplements (section
1.9.4) in patients with cystic fibrosis.
They can also be
used to control
excessive secretion of
gastric acid in
Zollinger–Ellison
syndrome
;
high
doses
are
often
required.
Cautions
Proton pump inhibitors may mask the symp-
toms of
gastric cancer;
particular
care is required in
those presenting with ‘alarm features’
(see p.
43),
in
such cases
gastric malignancy should be ruled out
before treatment.
Side-effects
Side-effects of
the proton pump inhi-
bitors include gastro-intestinal
disturbances (including
nausea, vomiting, abdominal pain, flatulence, diarrhoea,
constipation),
and headache.
Less frequent side-effects
include dry mouth,
peripheral oedema,
dizziness,
sleep
disturbances,
fatigue,
paraesthesia,
arthralgia,
myalgia,
rash,
and pruritus. Other side-effects reported rarely or
very rarely include taste disturbance,
stomatitis,
hepat-
itis,
jaundice,
hypersensitivity
reactions
(including
anaphylaxis,
bronchospasm),
fever,
depression,
halluci-
nations, confusion, gynaecomastia, interstitial nephritis,
hyponatraemia,
blood disorders (including leucopenia,
leucocytosis,
pancytopenia,
thrombocytopenia),
visual
disturbances,
sweating,
photosensitivity,
alopecia,
Ste-
vens-Johnson syndrome,
and toxic epidermal
necroly-
sis. By decreasing gastric acidity, proton pump inhibitors
may increase the risk of
gastro-intestinal
infections
(including
Clostridium difficile
infection).
ESOMEPRAZOLE
Indications
see under Dose
Cautions
see notes above; interactions: Appendix 1
(proton pump inhibitors)
Hepatic impairment
in severe hepatic impairment
max. 20 mg daily (
CHILD
1–12 years max. 10 mg daily);
for severe peptic ulcer bleeding in severe hepatic
impairment, initial intravenous infusion of 80 mg, then
by continuous intravenous infusion, 4 mg/hour for 72
hours
Renal impairment
manufacturer advises caution in
severe renal insufficiency
Pregnancy
manufacturer advises caution—no infor-
mation available
Breast-feeding
manufacturer advises avoid—no
information available
Side-effects
see notes above
Dose
. By mouth duodenal ulcer associated with
Helico-
bacter pylori
,
see eradication regimens on p.
50
NSAID-associated gastric ulcer,
ADULT
over 18 years,
20 mg once daily for 4–8 weeks; prophylaxis in
patients with an increased risk of gastroduodenal
complications who require continued NSAID treat-
ment,
20 mg daily
Gastro-oesophageal reflux disease (in the presence of
erosive reflux oesophagitis),
ADULT
and
CHILD
over 12
years, 40 mg once daily for 4 weeks,
continued for
further 4 weeks if not fully healed or symptoms
persist;
maintenance 20 mg daily;
CHILD
1–12 years,
body-weight 10–20 kg,
10 mg once daily for 8 weeks;
body-weight over 20 kg, 10–20 mg once daily for 8
weeks
Symptomatic treatment of gastro-oesophageal reflux
disease (in the absence of oesophagitis),
ADULT
and
CHILD
over 12 years, 20 mg once daily for up to 4
weeks,
then 20 mg daily when required;
CHILD
1–12
years, body-weight over 10 kg,
10 mg once daily for
up to 8 weeks
Zollinger–Ellison syndrome,
ADULT
over 18 years,
initially 40 mg twice daily,
adjusted according to
response;
usual range 80–160 mg daily (above 80 mg
in 2 divided doses)
.
By intravenous injection over at least 3 minutes
or
by
intravenous infusion,
ADULT
over 18 years,
gastro-
oesophageal reflux disease,
40 mg once daily; symp-
tomatic reflux disease without oesophagitis,
treat-
ment of NSAID-associated gastric ulcer, prevention of
NSAID-associated gastric or duodenal ulcer,
20 mg
daily; continue until oral administration possible
. Severe peptic ulcer bleeding (following endoscopic
treatment),
ADULT
over 18 years, initial intravenous
infusion of 80 mg over 30 minutes,
then by continu-
ous intravenous infusion 8 mg/hour for 72 hours,
then by mouth 40 mg once daily for 4 weeks
Nexium
c
(AstraZeneca) A
Tablets
, f/c, esomeprazole (as magnesium trihydrate)
20 mg (light pink),
net price 28-tab pack = £18.50;
40 mg (pink), 28-tab pack = £25.19.
Counselling,
administration
Counselling
Do not chew or crush tablets, swallow whole
or
disperse in water
Granules
,
yellow,
e/c,
esomeprazole (as magnesium
trihydrate) 10 mg/sachet, net price 28-sachet pack =
£25.19.
Label:
25,
counselling,
administration
Counselling
Disperse the contents of each sachet in approx.
15 mL water. Stir and leave to thicken for a few minutes; stir
again before administration and use within 30 minutes; rinse
container with 15 mL water to obtain full dose; can be
administered through nasogastric or gastric tube
Injection
,
powder for reconstitution,
esomeprazole
(as sodium salt), net price 40-mg vial = £3.13
With naproxen
Section 10.1.1
LANSOPRAZOLE
Indications
see under Dose
Cautions
see notes above; interactions: Appendix 1
(proton pump inhibitors)
Hepatic impairment
use half normal dose in moder-
ate to severe liver disease
Pregnancy
manufacturer advises avoid
Breast-feeding
avoid unless essential—present in
milk in
animal
studies
Side-effects
see notes above;
also glossitis,
pan-
creatitis,
anorexia,
restlessness,
tremor,
impotence,
petechiae,
and purpura;
very rarely
colitis,
raised
serum cholesterol or triglycerides
Dose
. Benign gastric ulcer, 30 mg daily in the morning for 8
weeks
. Duodenal ulcer,
30 mg daily in the morning for 4
weeks; maintenance 15 mg daily
. NSAID-associated duodenal or gastric ulcer,
30 mg
once daily for 4 weeks, continued for further 4 weeks if
not fully healed;
prophylaxis,
15–30 mg once daily
. Eradication of
Helicobacter pylori
associated with
duodenal ulcer or ulcer-like dyspepsia,
see eradica-
tion regimens on p.
50
BNF 61
1.3.5 Proton pump inhibitors
55
1
Gastro-intestinal system