Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole
Issues for Surgery
For regular, chronic use – risk of rebound hyperacidity if omitted.
Increased risk of pulmonary aspiration and / or stress-related mucosal disease if omitted.
For investigations of Helicobacter pylori (H. pylori) associated dyspepsia – risk of false negative if continued.
Advice in the Perioperative period
Patients who take ‘when required’ PPI should be advised to take a dose of their usual medication on the morning of surgery.
For patients with increased risk factors for aspiration (e.g. pregnancy, obesity, non-fasted state in emergency surgery) consider administration of acid-suppressing medication (oral or intravenous) perioperatively – see Further Information ‘PPIs vs. Histamine H2-Receptor Antagonists [H2RAs]. NB: PPIs are not licensed for prophylaxis of aspiration in relation to anaesthesia.
Patients Undergoing Anti-Reflux Surgery or Total Gastrectomy
Use of Post-operative Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
H2RAs are an alternative in those patients where PPIs are unsuitable (see Histamine H2-Receptor Antagonists (H2RAs) monograph).
Interaction(s) with Common Anaesthetic Agents
Increased benzodiazepine effects have been seen after omeprazole has been given with certain benzodiazepines (diazepam, flurazepam, lorazepam)3, 4. Diazepam exposure is slightly increased by esomeprazole3. The clinical significance is unclear, but should be borne in mind should any benzodiazepine adverse effects (drowsiness, sedation, ataxia) occur: consider reducing the benzodiazepine dose if necessary3.
Interaction(s) with other Common Medicines used in the Perioperative Period
Glossitis, stomatitis and black tongue have, very rarely been seen in patients given lansoprazole and certain antimicrobials (amoxicillin, clarithromycin and metronidazole) as part of triple therapy regimens for H. pylori3, 4. Given the wide use of H. pylori regimens containing these drugs it seems unlikely that the interaction is common3.
Whilst single surgical prophylactic doses should not pose a problem, if a prolonged course of antimicrobials is required post-operatively in patients on regular, long-term PPIs, bear in mind the increased risk of Clostridium difficile infection (CDI) in patients taking PPIs (see Further Information).
Long-Term use of PPIs
A PPI should be prescribed for appropriate indications at the lowest effective dose for the shortest period; the need for long-term treatment should be reviewed periodically1, 2. Long-term complications of PPI use include electrolyte disturbances (especially hypomagnesaemia), increased risk of fractures and gastro-intestinal infections (including CDI)1 – see below.
Clostridium difficile Infection (CDI)
The risk of CDI for patients taking PPIs is increased in hospitalised patients receiving antibiotics. Public Health England guidelines for managing and treating CDI recommend that consideration be given to stopping or reviewing the need for PPIs in patients with, or at high risk of, CDI5.
PPIs vs. Histamine H2- Receptor Antagonists (H2RAs)
Superiority of either class of acid-suppressing medication given perioperatively to reduce the risk of aspiration has not been definitely proven, although the majority of evidence supports the pre-operative administration of H2RAs in most patients, with PPI therapy being reserved for patients on chronic acid suppression who may have developed some degree of tolerance to such chronic acid suppression6, 7. Also see Histamine H2-Receptor Antagonists (H2RAs) monograph.