Ulcer Healing Drugs Notes & Guidance

 Dyspepsia Management Guidelines - Summary

A. Patients with dyspepsia in whom diagnostic endoscopy is appropriate.

1. Review medications for possible causes of dyspepsia (eg. theophyllines, bisphosphonates, corticosteroids & NSAIDs). In patients requiring referral, suspend NSAID use.
2. Pre treatment with anti-secretory drugs may mask significant diagnoses at endoscopy. For patients having their first endoscopy, it is advised that they stop their treatment 2 weeks before.

B. Interventions for uninvestigated dyspepsia

1. Initial theraputic strategies for dyspepsia are empirical treatment with a PPI or testing for and treating H. pylori. A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test, therefore it is preferable to test for H Pylori first and treat if necessary (result is available within 24 to 48 hours) to avoid a patient starting a PPI and then having to stop prior to a test.
2. Offer empirical full-dose PPI therapy for 4 weeks to people with dyspepsia.
3. If there is an inadequate response to a PPI, offer H2 receptor antagonist (H2RA) therapy instead.

C. Interventions for gastro-oesophageal reflux disease (GORD)

1. Offer patients who have GORD a full dose PPI for 4-8 weeks.
2. If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions.
3. Discuss with people how they can manage their own symptoms by using the treatment when they need it.
4. If there is an inadequate response to a PPI offer H2RA therapy instead.
5. Offer people a full-dose PPI for 8 weeks to heal severe oesophagitis, taking into account the person's preference and clinical circumstances (for example, underlying health conditions and possible interactions with other drugs).
6. If initial treatment for healing severe oesophagitis fails, consider a high dose of the initial PPI, switching to another full-dose PPI or switching to another high-dose PPI.
7. Offer a full-dose PPI long-term as maintenance treatment for people with severe oesophagitis, taking into account the person's preference and clinical circumstances (for example, tolerability of the PPI, underlying health conditions and possible interactions with other drugs), and the acquisition cost of the PPI.
8. If the person's 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.

D. Interventions for peptic ulcer disease

1. Offer H. pylori eradication therapy to H. pylori positive patients who have peptic ulcer disease.
2. For patients using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI for 2 months to these patients and if H. pylori is present, subsequently offer eradication therapy.
3. Offer people with gastric ulcer and H pylori repeat endoscopy 6 to 8 weeks after beginning treatment, depending on the size of the lesion.
4. Offer people with peptic ulcer (gastric or duodenal) and H pylori retesting for H pylori 6 to 8 weeks after beginning treatment, depending on the size of the lesion. First line drugs Second line drugs Specialist drugs Specialist only drugs
5. If symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to control symptoms. Discuss using the treatment on an 'as needed' basis with people to manage their own symptoms.

E. Interventions for functional dyspepsia

1. Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring.
2. Re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients.
3. If H. pylori has been excluded and symptoms persist, offer either a low-dose PPI or an H2RA for 4 weeks.
4. If symptoms continue or recur after initial treatment, offer a PPI or H2RA to be taken at the lowest dose possible to control symptoms.
5. Discuss using PPI treatment on an 'as-needed' basis with people to manage their own symptoms.

F. Reviewing patient care

1. Offer patients requiring long-term management of symptoms for dyspepsia an annual review of their condition, encouraging them to try stepping down or stopping treatment (unless there is an underlying condition or co-medication that needs continuing treatment).
2. A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over- the-counter and taken as required) may be appropriate.

G. H. pylori testing and eradication

1. H. pylori can be initially detected using carbon urea breath test or laboratory-based serology where its performance has been locally validated. The C urea breath test has a high sensitivity and specificity (>98%) and is non-invasive and is therefore the investigation of choice in primary care.
2. Surgery/office-based serological tests for H. pylori cannot be recommended because of their inadequate performance. In secondary care a stool antigen test may be used.
3. For patients who test positive provide eradication therapy as below taking into consideration:

a. Antibiotic allergies
b. Previous exposure to clarithromycin and metronidazole
c. Acquisition cost

Suggested regime for the eradication of Helicobacter pylori

OR
For penicillin allergic patients

OR
For penicillin allergic patients with previous exposure to clarithromycin

Second-line treatment

1. Offer people who still have symptoms after first-line eradication treatment a 7-day, twice-daily course of treatment with PPI, amoxicillin and the alternative antibiotic they did not receive as first line treatment.
2. Offer people who have had previous exposure to clarithromycin and metronidazole a 7-day, twice-daily course of treatment with a PPI, amoxicillin and a quinolone or tetracycline (whichever has the lowest acquisition cost).
3. Offer people who are allergic to penicillin (and who have not had previous exposure to a quinolone) a 7- day, twice-daily course of treatment with a PPI, metronidazole and levofloxacin.
4. Offer people who are allergic to penicillin and who have had previous exposure to a quinolone a PPI, bismuth, metronidazole and tetracycline.
5. Seek advice from a gastroenterologist if eradication of H pylori is not successful with second-line treatment.