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
01.03  Expand sub section  NSAID-associated ulcers

GI-bleeding and ulceration can occur with NSAID use. The risk of serious upper GI side-effects varies between individual NSAIDs. Whenever possible, the NSAID should be withdrawn if an ulcer occurs.
Patients at high risk of developing GI complications with a NSAID include those over 65 years, those with a history of peptic ulcer disease or serious GI complication, those taking other medicines athat increase the risk GI side-effects, or those with serious co-morbidity (e.g. cardiovascular disease, diabetes, renal or hepatic impairment).
In a patient who has developed an ulcer, if the NSAID can be discontinued, a proton pump inhibitor usually produces the most rapid healing. On healing, patients should be tested for H.pylori and given eradication therapy if indicated.

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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Traffic Light Status Information

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.   

Green SA

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

Amber SC

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]