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NICE guidance - management of oesophagitis in primary care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Management of Gastroesophageal reflux disease in Primary Care

Gastroesophageal reflux disease (GORD) in this guidance refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease. Patients with uninvestigated 'reflux-like' symptoms should be managed as patients with uninvestigated dyspepsia. There is currently no evidence that H. pylori should be investigated in patients with GORD.

Step (A) Endoscopy

  1. if mild/moderate oesophagitis then (A.1)
  2. if severe oesophagitis then (A.2)
  3. if endoscopic negative reflux disease then (A.3)

Step (A.1) mild/moderate oesophagitis on endoscopy - Full dose PPI for one or two months

  1. if response then low-dose treatment as required - offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions then (B)
  2. if no response then double-dose PPI for one month
    1. if response then offer low-dose treatment, possibly on an as-required basis then (B)
    2. if no response then double-dose PPI for 1 month
      1. if response then (B)
      2. if no response then H2RA or for one month
        1. if response then offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions then (B)
        2. if no response then (B)

Step (A.2) severe oesophagitis on endoscopy

  1. Full-dose PPI for 8 weeks
    1. if oesophagitis persists then Full / high-dose PPI for 8 weeks
      1. otherwise if oesophagitis healed continue full-dose PPI
    2. if oesophagitis persists despite second course of full/high dose PPI for 8 weeks then refer for specialist review

Step (A.3) Endoscopic negative reflux disease - Full-dose PPI for one month

  1. if response then offer low-dose treatment, possibly on an as-required basis then (B)
  2. if no response then H2RA or for one month
    1. if no response then (B)
    2. if response then offer low-dose treatment, possibly on an as-required basis, then (B)

Step (B) Review long-term patient care at least annually to discuss medication and symptoms.

  • in some patients with an inadequate response to therapy or new emergent symptoms it may become appropriate to refer to a specialist for a second opinion.
  • review long-term patient care at least annually to discuss medication and symptoms
  • a minority of patients have persistent symptoms despite PPI therapy and this group remain a challenge to treat. Therapeutic options include adding an H2RA at bedtime
    • consider a high-dose of the initial PPI, switching to another full-dose PP or switching to another high-dose PPI

Notes:

PPI

Full/Standard dose

Low dose (on demand dose)

Double dose/High dose

Esomeprazole

40 mg* once a day

20mg* once a day

40 mg* twice a day

Lansoprazole

30mg once a day

15mg per day

30 mg** twice a day

Omeprazole

40 mg* once a day

20mg* per day

40 mg* twice a day

Pantoprazole

40 mg once a day

20mg per day

40mg** twice a day

Rabeprazole

20mg once a day

10mg per day

20mg** twice a day

For full details then refer to the full guideline (1).

Reference:


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