Proton Pump Inhibitors (PPI's)

Question 1

What are some examples of PPI’s?

Answer 1

• Omeprazole
• Lansoprazole
• Esomeprazole
• Pantoprazole

Question 2

What is the aim of PPI’s?

Answer 2

To suppress gastric acid secretion

Question 3

How do PPI’s have their effect?

Answer 3

Irreversibly inhibit H+/K+ -ATPase in gastric parietal cells

Question 4

How can PPI’s be administered?

Answer 4

• PO

- IV

Question 5

What are the indications for PPI’s?

Answer 5

• GORD
• Gastro-duodenal ulcers
• H.pylori eradication (as part of triple therapy)
• Prophylaxis of ulceration in NSAID and steroid use
• Zollinger-Ellison syndrome

Question 6

What are the cautions for the use of PPI’s?

Answer 6

• Red flag cancer symptoms
• Risk of osteoporosis
• Hepatic impairment

Question 7

How should PPI’s be prescribed in hepatic impairment?

Answer 7

• Lower dose

- Renal function monitoring

Question 8

What monitoring may patients of PPI’s require?

Answer 8

Magnesium levels

Question 9

How can PPI’s affect magnesium levels?

Answer 9

Can cause hypomagnesaemia between 3 months to 1 year

Question 10

What drugs does omeprazole interact with?

Answer 10

• Warfarin
• Clopidogrel

Omeprazole decreases efficacy of these drugs

Question 11

What other drug can PPI’s interact with?

Answer 11

Digoxin

Question 12

What can PPI’s and digoxin together cause?

Answer 12

Hypomagnesaemia

Question 13

What are the common side-effects of PPI’s?

Answer 13

• GI disturbances
• Dry mouth
• Headaches
• Fatigue

Question 14

What are the less common side-effects of PPI’s?

Answer 14

• Increased risk of C.diff

- Increased risk of osteoporosis

Question 15

What mnemonic can be used to remember the side-effects of PPI’s?

Answer 15

PPI

Question 16

What does the PPI mnemonic stand for?

Answer 16

• Pain (headache, abdo pain)
• Prone to C.diff and osteoporosis
• Intestinal upset

Question 17

What counselling should be given to patients on PPI’s?

Answer 17

• Measures to further reduce acidity
• Ensure compliance
• Adequate vit D and calcium intake
• Red flags of gastric cancer

Question 18

What should the patient be told regarding measures to further reduce acidity?

Answer 18

Explain that drug reduces acidity of stomach and should hopefully ease symptoms, but advise patient to avoid foods and drinks that exacerbate symptoms, to avoid large meals particularly late in evening, and avoid lying down immediately after eating

Question 19

What should the patient be told regarding compliance with PPIs?

Answer 19

Emphasise the importance of compliance, particularly if this drug has been co-prescribed with other drugs for prophylaxis of ADR

Question 20

What should be patients be told regarding preventing osteoporosis with PPIs?

Answer 20

Advise patients who are at risk of osteoporosis to maintain an adequate intake of vitamin D and calcium

Question 21

What should be done in a patient taking a PPI who might struggle to maintain an adequate intake of calcium?

Answer 21

Consider prescribing prophylactic therapy, e.g. bisphosphonates

Question 22

What should a patient on PPIs be told regarding red flags of cancer?

Answer 22

Inform patients about red flag symptoms of gastric cancer, and tell them to report these to GP. PPIs can mask symptoms of gastric cancer, so it is important to have a high index of suspicion