Authors' objectives:

To provide guidance on the use of proton pump inhibitors (PPI) in the treatment of dyspepsia.

Authors' recommendations: Guidance 1.1 In patients with documented duodenal or gastric ulcers, a treatment strategy of testing for Helicobacter pylori and, where positive, eradicating the infection is recommended. Long-term acid-suppressing therapy should not be used. Those patients who are H.pylori negative or remain symptomatic after eradication therapy should be treated as described in 1.6 1.2 For patients with a documented non-steroidal anti-inflammatory drug (NSAID)-induced ulcer, who must unavoidably continue with NSAID therapy (e.g. those with severe rheumatoid arthritis), an acid suppressor, usually a proton pump inhibitor (PPI), should be prescribed. After the ulcer has healed, the patient, where possible, should be stepped down to a maintenance dose of the acid suppressor. 1.3 Patients who have severe gastro-oesophageal reflux disorder (GORD) symptoms or who have a proven pathology (e.g. oesophageal ulceration, Barretts oesophagus) should be treated with a healing dose of a PPI until symptoms have been controlled. After that has been achieved, the dose should be stepped down to the lowest dose that maintains control of symptoms. A regular maintenance low dose of most PPIs will prevent recurrent GORD symptoms in 70-80% of patients and should be used in preference to the higher healing dose. Where necessary, should symptoms re-appear, the higher dose should be recommenced. In complicated oesophagitis (stricture, ulcer, haemorrhage), the full dose should be maintained. Patients with mild GORD symptoms and/or those who do not have a proven pathology can frequently be managed by alternative therapies (at least in the first instance) including antacids, alginates, or H2RAs (H2 receptor antagonists). 1.4 Patients diagnosed with non-ulcer dyspepsia (NUD) may have symptoms caused by different aetiologies and should not be routinely treated with PPIs. Should the symptoms appear to be acid-related, an antacid or the lowest dose of an acid suppressor to control symptoms should be prescribed. If they do not appear to be acid-related, an alternative therapeutic strategy should be employed. 1.5 Patients presenting in general practice with mild symptoms of dyspepsia may be treated on either a step-up or a step-down basis. Neither group should normally be treated with PPIs on a long-term basis without a confirmed clinical diagnosis being made. 1.6 In circumstances where it is appropriate to use a PPI and where healing is required, the optimal dose to achieve this should be prescribed initially. Once healing has been achieved, or for conditions where it is not required, the lowest dose of the PPI that provides effective symptom relief should be used. 1.7 The least expensive appropriate PPI should be used. 1.8 The use of PPIs in paragraphs 1.1 to 1.7 refers for each indication only to those PPIs which have been licensed for that use. 1.9 On present evidence, PPIs do not have any serious contraindications for the vast majority of users, and have been in common use for some eight or nine years. While their use in sufficient dosage to cure, or to control symptoms, is well warranted in terms of their clear benefits, any additional use cannot be recommended.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.nice.org.uk/page.aspx?o=TA007

Year Published: 2000

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: National Institute for Clinical Excellence

Contact Address: MidCity Place, 71 High Holborn, London WC1V 6NA, UK. Tel: +44 020 7067 5800; Fax: +44 020 7067 5801

Contact Name: nice@nice.nhs.uk

Contact Email: nice@nice.nhs.uk

Copyright: National Institute for Clinical Excellence (NICE)