Proton pump inhibitors in primary care

National Prescribing Service Limited (NPS) has released a prescribing practice review for the use of proton pump inhibitors (PPIs) in primary care. PPIs are a standard treatment for gastro-oesophageal reflux disease (GORD). Continuous use at a standard dose is common practice, but may represent more intensive therapy than many patients require.

The document advises that a single initial 4-week course be prescribed in uninvestigated dyspepsia or newly diagnosed GORD. A single initial course of standard-dose PPI will control symptoms and heal gastro-oesophageal lesions. Step down to intermittent, symptom-driven PPI therapy, or to a lower dose if maintenance is required. If severe or complicated oesophagitis has been established by endoscopy, continuous standard-dose maintenance therapy is indicated.

If dyspepsia without predominant GORD symptoms (gastrointestinal bleeding, upper abdominal mass, difficulty/pain on swallowing, unexplained weight loss or persistent vomiting) presents it is recommended to test-and-treat for Helicobacter pylori infection.

To step down PPI therapy, it is recommended that the maintenance therapy be reviewed once or twice yearly. Step down to intermittent or low-dose therapy if symptoms are well controlled. Continuous low-dose PPI maintenance therapy controls symptoms in most people who have completed a 4-week course of standard-dose therapy.

The patient should be told the goal of initial or ongoing therapy with a PPI. When referring for an endoscopy, specific details about the need for and duration of ongoing therapy should be requested. The indication for PPIs prescribed in hospital may be unclear at discharge. If the need for ongoing therapy is uncertain, stop the PPI and review before prescribing a further course.

Self-management is effective for mild or intermittent symptoms of dyspepsia. Randomised controlled trials in non-erosive and mild-erosive GORD show that intermittent symptom-driven maintenance therapy after initial healing results in patient satisfaction rates similar to those for continuous therapy, even though patients experience some symptoms. Patients are advised to return for review if they experience alarm symptoms or recurrent troublesome dyspepsia or reflux.

Patients aged 65 years or more who use NSAIDs have a high risk of NSAID-related gastrointestinal ulcer complications. NSAID use should be minimised. PPIs reduce NSAID-related dyspepsia, but it is uncertain how well they prevent clinical ulcer complications.

Gastroprotection should only be considered for high-risk patients, as the benefit is small in patients without risk factors for ulcers and may not outweigh the costs and harms. The recommended gastroprotective strategies are co-prescribing a PPI, double-dose H₂ antagonist or misoprostol with a conventional NSAID, or substituting a COX-2 selective NSAID.