netFormulary George Eliot Hospital NHS
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 Formulary Chapter 1: Gastro-intestinal system - Full Chapter

Chapter complete - updated July 18

01.03  Expand sub section  Antisecretory drugs and mucosal protectants
01.03  Expand sub section  Helicobacter pylori infection

Eradication of Helicobacter pylor reduces recurrence of gastric and duodenal ulcers and the risk of rebleeding, the presence of H.pylori should be confirmed before starting eradication treatment. Acid inhibition combined with antibacterial treatment is highly effective in the eradication of H.pylori; reinfection is rare.
For initial treatment, a one-week triple-therapy regimen that comprises a proton pump inhibitor, clarithromycin and either amoxicillin or metronidazole can be used. These regimens eradicate H.pylori in about 85% of cases, there is usually no need to continue antisecretory treatment (with a proton pump inhibitor or H2-receptor antagonist), however, if the ulcer is large, or complicated by haemorrhage or performation, then antisecretory treatment is continued for a further 3 weeks.

01.03  Expand sub section  NSAID-associated ulcers
01.03.01  Expand sub section  H2-receptor antagonists

Histamine H2-receptor antagosits heal gastric and duodenal ulcers by reducing gastric acid output as a result of histamine H2-receptor blockade; they are also used to relieve symptoms of GORD. Maintenance treatment with low doses for the prevention of peptic ulcer disease has largely been replaced in H.pylori positive patients by eradication regimens. In adults, H2-receptor antagonists are used for the treatment of functional dyspepsia and may be used for the treatment of uninvestigated dyspepsia without alarm features. H2-receptor antagonist therapy can promote healing of NSAID-associated ulcers (particularly duodenal) and also reduce the risk of acid aspiration in obstetric patients at delivery.

01.03.05  Expand sub section  Proton pump inhibitors (PPIs) to top

PPIs are effective short term treatments for gastric and duodenal ulcers; they are also used in combination with antibacterials for the eradication of H.Pylori and can be used for the treatment of dyspepsia and GORD. PPIs are also used for the prevention and treatment of NSAID associated ulcers. In patients who need to continue NSAID treatment after an ulcer has healed. the dose of PPI should normally not be reduced because asymptomatic ulcer deterioration may occur.

Particular care is required in those presenting with 'alarm featurs', in such cases gastric malignancy should be ruled out before treatment.

Measurement of serum magnesium concentrations should be considered before and durring prolonged treatment with a PPI, especially when used with other drugs than can cause hypomagnesaemia or with digoxin.

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Status Description

Red SO

SPECIALIST ONLY - These drugs are deemed to be not appropriate for prescribing by GPs. Specialists should not ask GPs to prescribe these drugs.   

Green SI

SPECIALIST INITIATED - These drugs must be initiated, i.e. the first dose prescribed, by the specialist and then may be continued when appropriate by the patients GP following communication from the specialist.   

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SPECIALIST ADVISED Specialists may simply advise a patients GP to initiate these drugs themselves after they have made an initial assessment.   

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SHARED CARE - Responsibility for prescribing may be transferred from secondary to primary care with the agreement of an individual GP and when agreed shared care arrangements have been established. The specialist MUST stabilize the patient before asking for care to be transferred. Only specialists should initiate these drugs. Prescribing should be transferred to GPs according to an Shared Care Agreement [SCA]