Contents:
- Treatment options
- Role of other agents
- Prescribing information
Mechanism of action
PPIs inhibit gastric acid secretion by irreversibly inhibiting the proton pump (H+/K+ -ATPase), thereby blocking gastric acid secretion (5).
Common Indications in Palliative Care
- Dyspeptic symptoms unresolved by other medications/distressing to patient without
treatment - Prevention and treatment of gastro-intestinal (GI) bleeding
- Malignant Bowel Obstruction
Dosing
There is currently insufficient published evidence to recommend one PPI over another.
Accordingly, this guidance suggests that any of the following PPIs would be a reasonable option.
Reduce doses in severe hepatic impairment.
(1, 5)
- Maximum daily dose should be reduced in severe hepatic impairment
- Rebound acid hypersecretion and dyspepsia can occur after stopping long term PPIs
- May increase risk of gastro-intestinal infections e.g. clostridium difficile
- May reduce absorption of vitamin B12
- May increase risk fractures when used at high doses for >1 year (less likely in our cohort)
- Severe hypomagnesaemia if used long term
- Increased risk of pneumonia
- Hyponatraemia (risk Syndrome Inappropriate ADH with PPI use)
Esomeprazole and omeprazole are weak-moderate inhibitors of CYP2C19. Important interactions include:
- Inhibition of the metabolism of citalopram and escitalopram, increasing the risk of QT interval prolongation (see SSRIs and QT prolongation); the maximum daily dose should be reduced (see SPC) (10)
- A reduction in the antithrombotic effect of clopidogrel (a pro-drug activated by CYP2C19); avoid concurrent use with any PPI, use an H2 antagonist instead (11)
- Inhibition of the metabolism of diazepam
- Inhibition of the metabolism of warfarin; isolated reports of raised INR with all PPIs. (9)
H2 Receptor Antagonists
Although SC Ranitidine is no longer in production, famotidine is widely available and, although unlicensed for SC administration, there are reports of safe use via this route though evidence is lacking. Famotidine injection is not available in the UK but can be imported as a special product – liaise with your pharmacy teams for further advice and costings.
Suggested administration guidance as per PCF8:
Famotidine 20mg can be given IV b.d. diluted to 5mL with sodium chloride 0.9% and given over 2min
- Famotidine 20mg SC b.d. as a SC infusion or neat bolus (case series poster, n=35) (11) or
- Famotidine 40mg/24h CSCI, using WFI or sodium chloride 0.9% as diluent. (10)
Reduce doses in renal impairment
Refer to local formulary/guidance – may be specialist use only. Some items are classed as hospital only and therefore will affect community availability.
- Omeprazole 40mg powder for solution for infusion vials (pack of 5)
- Esomeprazole 40mg powder for solution for injection vials (pack of 5)
- Pantoprazole 40mg powder for solution for injection vial (pack of 1 or 5)
- Famotidine 20mg/2ml injection vial – (requires fridge storage) – not available in UK unless special order/import
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.