Download Prescribing Matters Please circulate to all prescribers, including

Prescribing Matters
Please circulate to all prescribers, including nurses, registrars and locums.
Newsletter archive can be found at: http://nww.hastingsandrothergpinfo.nhs.uk/gp/prescribing/index.asp
http://nww.esdwgpinfo.nhs.uk/prescribing/index.asp
Issue 158 Sept 2014
In this issue:
Domperidone no longer OTC
Generic sildenafil Rx quantities
NICE CG184: dyspepsia and GORD
Domperidone no longer available OTC
In line with the recent prescribing restrictions, domperidone is now no longer available OTC.
NB please ensure you have reviewed all your patients using domperidone.
Generic sildenafil Rx quantities
With generic sildenafil (and some other lesser used ED treatments – see last newsletter) no longer
SLS restricted, the question occurs as to whether the DoH guidance to only prescribe up to 4
treatments per month on the NHS still applies.
There has been no official communication about this, but we believe that this guidance no longer
applies.
HOWEVER sildenafil still has a street value so sensible prescribing should prevail.
We would also like to remind prescribers that you cannot provide an NHS Rx for (e.g) 4 tablets and
then a private Rx as a top-up; if the patient is eligible for NHS treatment then you should prescribe a
quantity you think is clinically appropriate on the NHS. If the patient wants more than you are happy
to prescribe, then they will have to source this themselves privately.
NICE CG184: Dyspepsia and GORD: Investigation and management of
dyspepsia, symptoms suggestive of GORD, or both
http://www.nice.org.uk/Guidance/CG184
PPI doses defined as:
Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
Rabeprazole
Low dose (on-demand
dose)
20mg od
15mg od
20mg od
20mg od
10mg od
Full/standard dose
High/double dose
40mg od
30mg od
40mg od
40mg od
20mg od
40mg bd
30mg bd
40mg bd
40mg bd
20mg bd
Note: the CCG are producing a patient leaflet for PPIs which will be available on HARMLESS/
GRACE soon.
Medication review
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
1
Review medications for possible causes of dyspepsia (e.g. calcium antagonists, nitrates,
theophyllines, bisphosphonates, corticosteroids and NSAIDs).
Reviewing patient care
Offer people who need long-term management of dyspepsia an annual review, and encourage them
to try stepping down or stopping treatment (unless there is an underlying condition or comedication
that needs continuing treatment):
- use the effective lowest dose
- try prn use when appropriate
- return to self-treatment with antacid and/or alginate therapy.
GORD
Manage uninvestigated 'reflux-like' symptoms as uninvestigated dyspepsia.
Offer people with GORD a full-dose PPI for 4 or 8 weeks.
If symptoms recur after initial treatment, offer a PPI at the lowest dose possible to control symptoms.
Discuss prn treatment.
Offer H2RA therapy if there is an inadequate response to a PPI (we have clarified with NICE, and this
is instead of PPI, not in addition to PPI; there are very limited circumstances where there is evidence
of benefit of PPI + H2RA).
People who have had dilatation of an oesophageal stricture should remain on long-term full-dose PPI.
Severe oesophagitis
- Full-dose PPI for 8 weeks to heal, then full-dose PPI long-term as maintenance treatment.
- If initial treatment for healing severe oesophagitis fails, consider a high dose of the initial PPI,
or switching to another full-dose or high-dose PPI.
- If severe oesophagitis fails to respond to maintenance treatment, carry out a clinical review.
Consider switching to another PPI at full dose or high dose, and/or seeking specialist advice.
Peptic ulcer disease
Offer H pylori eradication if tested positive; retest for H pylori after 6 to 8 weeks.
For people using NSAIDs with diagnosed peptic ulcer, stop the NSAID where possible. Offer full-dose
PPI or H2RA therapy for 8 weeks and, if H pylori is present, subsequently offer eradication therapy.
Offer full-dose PPI or H2RA therapy for 4 to 8 weeks to people who have tested negative for H pylori
who are not taking NSAIDs.
For people continuing to take NSAIDs after a peptic ulcer has healed:
- discuss the potential harm from NSAID treatment
- review the need for NSAID use regularly (at least every 6 months)
- offer a trial of prn use
- consider reducing the dose, substituting an NSAID with paracetamol, or using an alternative
analgesic or low-dose ibuprofen (1.2 g daily).
In people at high risk (previous ulceration) who need to continue their NSAID, offer gastric protection
(i.e. low dose PPI) or consider substitution with a COX-2.
In people with an unhealed ulcer, exclude non-adherence, malignancy, failure to detect H pylori,
inadvertent NSAID use, other ulcer-inducing medication and rare causes such as Zollinger–Ellison
syndrome or Crohn's disease.
If symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to control
symptoms. Discuss prn treatment.
Offer H2RA therapy if there is an inadequate response to a PPI (we have clarified with NICE, and this
is instead of PPI, not in addition to PPI; there are very limited circumstances where there is evidence
of benefit of PPI + H2RA).
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
2
Uninvestigated dyspepsia
Includes uninvestigated ‘reflux-like’ symptoms.
Offer H pylori 'test and treat' to people with dyspepsia.
(Leave a 2-week washout period after PPI use before testing for H pylori with a breath test or a stool
antigen test.)
Treat with full-dose PPI for 4 weeks.
If symptoms return, step down PPI therapy to the lowest dose needed to control symptoms. Discuss
prn treatment.
Offer H2RA therapy if there is an inadequate response to a PPI (we have clarified with NICE, and this
is instead of PPI, not in addition to PPI; there are very limited circumstances where there is evidence
of benefit of PPI + H2RA).
Functional dyspepsia
Manage endoscopically determined functional dyspepsia using initial treatment for H pylori if present,
followed by symptomatic management and periodic monitoring.
Do not routinely offer H pylori re-testing after eradication.
If H pylori has been excluded and symptoms persist, offer a low-dose PPI or an H2RA for 4 weeks.
If symptoms continue or recur after initial treatment, offer a PPI or H2RA to be taken at the lowest
dose possible to control symptoms. Discuss prn treatment.
Avoid long-term, frequent dose, continuous antacid therapy.
H pylori eradication
Offer people who test positive for H pylori a 7-day, twice-daily course of treatment with PPI with the
following Abx:
First line treatment
Standard
Penicillin
allergy
Penicillin
allergy AND
previous
exposure to
clarithromycin
Amoxycillin

(usually 1g bd)
Clarithromycin


(usually 250mg
(or
/ 500mg bd)
metronidazole)
Metronidazole



(usually 400mg
(or
bd / tds)
clarithromycin)
Bismuth

(usually 120mg
qds)
Tetracycline

(usually 500mg
qds)
Quinolone
(usually cipro
500mg bd)
Levofloxacin
(usually 500mg
od)
* either clarithromycin OR metronidazole to be used, not both
Note: these regimes differ from current BNF advice
Second line treatment
Standard Previous
exposure to
clarithromycin
and
metronidazole

Penicillin
allergy and
no
previous
exposure
to
quinolone
Penicillin
allergy
with
previous
exposure
to
quinolone



 (if not
used first
line)*
 (if not
used first
line)*



(or quinolone)

(or tetracycline)

Seek gastro advice if eradication of H pylori is not successful with second-line treatment.
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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