GASTROINTESTINAL SYSTEM MANAGEMENT OF DYSPEPSIA

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1 GASTROINTESTINAL SYSTEM MANAGEMENT OF DYSPEPSIA MANAGEMENT Dyspepsia refers to a spectrum of usually intermittent upper gastrointestinal symptoms, including epigastric pain and heartburn. For the majority of patients the consequence of dyspepsia is symptoms affecting their quality of life. The impact of this being on the quality of life is a personal experience, a reoccurring problem or a chronic complaint for which the available treatments may be wholly or partially effective to relieve symptoms. Lifestyle changes can help to avoid triggering dyspepsia. Lifestyle advice includes healthy eating, weight reduction and smoking cessation. URGENT REFERRAL Patients who present with alarm symptoms as indicated below should be referred to secondary care: dyspepsia with gastrointestinal bleeding difficulty in swallowing (dysphagia) progressive unintentional weight loss abdominal swelling persistent vomiting persistent weight loss and vomiting or iron deficiency anaemia in the absence of dyspepsia unexplained worsening dyspepsia and Barrett s oesophagus, or peptic ulcer surgery over 20 years ago. Urgent endoscopy for patients aged 55 and over with unexplained and persistent recent-onset dyspepsia alone All patients should have their medication reviewed to check if they are prescribed any medications that may cause dyspepsia such as calcium channel blockers, nitrates, theophyllines, bisphosphonates, corticosteroids and NSAID s. It is also vital that any over-the-counter medicines are reviewed. 1

2 DRUG CHOICES Antacids Co-magaldrox (Mucogel ) Asilone (contains simethicone) 10-20mls three times a day 5-10mls after meals and at bedtime up to four times a day Liquid preparations are more effective than tablet preparations. Antacids are best given when symptoms occur or are expected usually between meals and at bedtime, 4 or more times daily. Additional doses maybe required up to once an hour. Both formulations are low in Sodium content. Alginates Peptac Gaviscon Advance Gastrocote tablets 10-20mls after meals and at bedtime 5-10mls after meals and at bedtime 1 to 2 tablets chewed 4 times daily after meals and at bedtime Liquid preparations are more effective than tablet preparations. To be used in caution in patients with diabetes- high sugar content. H2-receptor antagonists Ranitidine tablets 150mg or 300mg Usually up to 150mg 4 times daily or 300mg twice daily Should be used in caution in renal impairment, pregnancy and breastfeeding. Proton Pump Inhibitors First Line Choice 20-40mg daily for 28 days then reduce ADVISE TO TAKE PPI S 20 MINUTES BEOFRE BREAKFAST. Reduce to suitable maintenance dose 20-10mg daily i.e. the minimum dose that is required to control symptoms 30mg daily for 28 days then reduce Reduce to suitable maintenance dose 15mg daily i.e. the minimum dose that is required to control symptoms 2

3 In both cases are more cost-effective compared to tablets. However tablets maybe required in some patients who will not take due to a religious or ethical background. Specific Indication orodispersible tablets (Zoton FasTab ) This should be reserved for patients with swallowing difficulties or who may require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. orodispersible tablets (Zoton FasTab ) 30mg daily for 28 days then reduce H. Pylori Eradication First Line for 1 week treatment only Prescribing is reserved for specific indications as detailed above. Tablets should be placed on the tongue and allowed to disperse and then swallowed. If required tablets can be dissolved in water and given via NG or PEG tube. or () +Clarithromycin +Metronidazole +Metronidazole 30mg BD 20mg BD 1g BD 500mg BD 30mg BD 1g BD 400mg BD 20mg BD 500mg TDS 400mg BD Stop any currently prescribed proton pump inhibitors 2 weeks prior and antibiotics 4 weeks prior to the Helicobacter pylori breath test or endoscopy. Emphasise compliance with treatment, possible success rate of 85%. If patient needs another course of treatment a different regime should be prescribed. Refer to latest BNF section 1.3 for recommended regimes. Patients who are allergic to penicillin may receive tetracycline 500mg twice daily instead of amoxicillin 1mg twice daily. 3

4 NSAID associated Ulcers and dyspepsia Ulcer Treatment Comments Duodenal Ulcer Gastric Ulcer Continue with full dose of PPI for 4 weeks Continue with full dose of PPI for up to 8 weeks - repeat endoscopy. In both cases: Preferably stop NSAID s / Aspirin If not possible to stop NSAIDs / Aspirin and: 1. H-Pylori positive then confirm with breath test and unless patient high risk should not treat with concurrent PPI and NSAID / aspirin 2. H-Pylori negative then concurrent PPI and NSAID / aspirin. Possible association between concomitant use of PPIs with Clopidogrel reducing the effectiveness of clopidogrel. OR Consider reviewing the clinical need for clopidogrel NSAID associated Ulcers and dyspepsia 20mg daily for 4-8 weeks Can be used prophylatically in patients with a history of NSAID dyspeptic symptoms, associated ulcers or gastroduodenal lesions mg daily for 4-8 weeks (or until gastric ulcers healed) Can be used prophylatically in patients with a history of NSAID dyspeptic symptoms, associated ulcers or gastroduodenal lesions at 15-30mg daily. Patients prescribed low dose Aspirin 75mg daily and who are at risk of NSAID associated ulcers should be prescribed a proton pump inhibitor concomitantly instead of replacing aspirin with clopidogrel. Check if H-Pylori positive or negative. Patients requiring a parenteral proton pump inhibitor may be prescribed intravenous omeprazole. 4

5 Non-ulcer Dyspepsia Domperidone 10mg tablets 10-20mg to be taken three times a day 30 minutes before meals and at night for up to 12 weeks Advise patient of possible side-effects See latest BNF or SPC. References 1. The National Institute for Health and Clinical Excellence. Quick Reference Guide Dyspepsia management of dyspepsia in adults in Primary care Clinical Guideline 17 August The National Institute for Health and Clinical Excellence. Quick Reference Guide Referral Guidelines for suspected cancers - Clinical Guideline 27 June The British National Formulary - Latest version 5

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