Dyspepsia
Dyspepsia denotes a symptom and not a disease. It is a short-term problem in the majority of patients.
Antacids.
Alginates. Please note there is a lower dosage advised for Gaviscon Advance products compared to Peptac.
Proton pump inhibitors.
Lansoprazole orodispersible tablets are for use only in patients with swallowing difficulties, or for administration via nasogastric or percutaneous endoscopic gastrostomy tube.
Prescribing Notes:
- Lifestyle changes are often required, such as raising the head of the bed, weight reduction, reduction of alcohol, smoking cessation and avoidance of aggravating foods.
- Compound alginic acid preparations are less powerful antacids than co-magaldrox but may be more effective for heartburn.
- PPIs are most effective when taken on an empty stomach, 20-30 minutes before breakfast.
- One week’s treatment may be sufficient to determine if dyspepsia will respond and whether it is self-limiting.
- Antacids should be used for 10-14 days when withdrawing PPI treatment, to help with rebound symptoms. PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridioides difficile (C.diff) infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
- Antacids, taken at the same time as other drugs, may impair their absorption. They may also damage enteric coatings designed to prevent irritant drugs from dissolving in the stomach.
History Notes
15/04/2026
Regional formulary chapter launched.
For eradication for 7 days only, PPI plus two antibiotics (see below).
PPI choices: omeprazole or lansoprazole.
20mg twice daily for seven days.
30mg twice daily for seven days.
And amoxicillin.
1g twice daily for seven days.
And either clarithromycin or metronidazole. If clarithromycin or metronidazole has been prescribed in the last year use an alternative.
500mg twice daily for seven days.
400mg twice daily for seven days.
For second line treatment, repeat first line options but change clarithromycin or metronidazole for the option not used first line.
Each Pylera capsule contains 140mg bismuth subcitrate potassium,125mg metronidazole and 125mg tetracycline hydrochloride.
3 capsules four times a day, for ten days.
20mg twice daily for ten days.
Prescribing Notes:
- The regional formulary will not cover all eventualities for infections medicines choices. As with any condition; patient specific factors and sensitivities need to be considered. Please consider this regional formulary advice alongside any relevant local Board guidelines.
- If first line antibiotic treatment fails, move to second line.
- If eradication failure occurs, never repeat the same treatment course. Patients who fail second line therapy should be referred for specialist advice (gastro-intestinal medicine). Amoxicillin, clarithromycin, metronidazole, or tetracycline are options, refer to BNF treatment summaries for Helicobacter pylori infection. Tetracycline 500mg four times daily may be used only under the recommendation of a specialist.
- If a course of clarithromycin or metronidazole has been taken in the last year for any infection, that antibiotic should not be used in the eradication regime.
- Stop PPI’s 2 weeks before and antibiotics 4 weeks before Helicobacter pylori faecal antigen test.
- Symptoms may persist for some weeks. In this event, continue proton pump inhibitor therapy for up to 4 weeks.
- Patients who are experiencing symptoms of GORD are not likely to improve with H. pylori eradication therapy. In those with chronic GORD, however, in whom long-term PPI therapy is anticipated, H. pylori eradication is recommended.
- PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridium difficile infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
- In the absence of alarm symptoms, current practice is to treat empirically or ‘test and treat’ all patients with suspected GORD or peptic ulcer disease.
History Notes
30/07/2026
Pathway added following the launch of the Infections chapter.
If allergic to penicillin. For eradication for 7 days only, PPI plus two antibiotics (see below).
PPI choices: omeprazole or lansoprazole.
20mg twice daily for seven days.
30mg twice daily for seven days.
And two antibiotics (metronidazole and clarithromycin). If metronidazole has been prescribed in the last year use an alternative.
400mg twice daily for seven days.
500mg twice daily for seven days.
Each Pylera capsule contains 140mg bismuth subcitrate potassium,125mg metronidazole and 125mg tetracycline hydrochloride.
3 capsules four times a day, for ten days.
20mg twice daily for ten days.
Prescribing Notes:
- The regional formulary will not cover all eventualities for infections medicines choices. As with any condition; patient specific factors and sensitivities need to be considered. Please consider this regional formulary advice alongside any relevant local Board guidelines.
- If first line antibiotic treatment fails, move to second line.
- If eradication failure occurs, never repeat the same treatment course. Patients who fail second line therapy should be referred for specialist advice (gastro-intestinal medicine). Amoxicillin, clarithromycin, metronidazole, or tetracycline are options, refer to BNF treatment summaries for Helicobacter pylori infection. Tetracycline 500mg four times daily may be used only under the recommendation of a specialist.
- If a course of clarithromycin or metronidazole has been taken in the last year for any infection, that antibiotic should not be used in the eradication regime.
- Stop PPI’s 2 weeks before and antibiotics 4 weeks before Helicobacter pylori faecal antigen test.
- Symptoms may persist for some weeks. In this event, continue proton pump inhibitor therapy for up to 4 weeks.
- Patients who are experiencing symptoms of GORD are not likely to improve with H. pylori eradication therapy. In those with chronic GORD, however, in whom long-term PPI therapy is anticipated, H. pylori eradication is recommended.
- PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridium difficile infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
- In the absence of alarm symptoms, current practice is to treat empirically or ‘test and treat’ all patients with suspected GORD or peptic ulcer disease.
History Notes
30/07/2026
Pathway added following the launch of the Infections chapter.
If NSAID-induced gastro-intestinal bleeding or ulceration occurs the NSAID should ideally be stopped, and omeprazole or lansoprazole prescribed.
Omeprazole capsules should be prescribed rather than tablets, as tablets are more expensive with no additional benefit.
Prescribing Notes:
- Lansoprazole orodispersible tablets should be reserved for patients with swallowing difficulties or who require a proton pump inhibitor via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube. Lansoprazole orodispersible tablets are preferred to omeprazole dispersible tablets.
- PPIs are most effective when taken on an empty stomach, 20-30 minutes before breakfast.
- Patients receiving low dose aspirin 75mg daily, who are at risk of NSAID-associated ulcers, should be prescribed a proton pump inhibitor concomitantly instead of replacing aspirin with clopidogrel.
- PPIs should be used with caution in the elderly. There may be an association between PPI use and Clostridioides difficile (C.diff) infection and osteoporosis. Careful consideration should be made to the risk benefit ratio.
- Step down treatment from 20mg omeprazole daily (or equivalent), or "on demand treatment" may be appropriate when symptoms are controlled.
- Stepping down treatment is NOT appropriate for the following groups:
- People with complicated oesophagitis (LA Grade C & D).
- People taking PPI for gastroprotection against NSAID.
- Those with a previous bleeding peptic ulcer, remaining H. pylori positive after at least 2 eradication attempts.
- Patients should have:
- 2 weeks off PPI and 4 weeks off antibiotics prior to H. pylori faecal antigen test or breath test;
- Antacids/alginates are the preferred treatment during this period;
- Patients on PPIs are encouraged to increase their intake of dietary calcium.
History Notes
15/04/2026
Regional formulary chapter launched.
Antacids.
Alginates. Please note there is a lower dosage advised for Gaviscon Advance products compared to Peptac.
History Notes
15/04/2026
Regional formulary chapter launched.
History Notes
15/04/2026
Regional formulary chapter launched.