Racecadotril 11-Feb-2016 l INDICATIONS AND DOSE
4.2 Gastric and duodenal ulceration
lHEPATIC IMPAIRMENTIn patients withfluid retention avoid antacids containing large amounts of sodium. Avoid antacids containing magnesium salts in hepatic coma if there is a risk of renal failure.
lRENAL IMPAIRMENT Magnesium trisilicate and
magnesium carbonate mixtures have high sodium content;
avoid in patients withfluid retention.
lPRESCRIBING AND DISPENSING INFORMATIONWhen prepared extemporaneously, the BP states Magnesium Trisilicate Mixture, BP consists of5% each of magnesium trisilicate, light magnesium carbonate, and sodium bicarbonate in a suitable vehicle with a peppermint flavour.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Magnesium trisilicate with magnesium carbonate and sodium bicarbonate (Non-proprietary)
Magnesium carbonate light 50 mg per 1 ml, Magnesium trisilicate 50 mg per 1 ml, Sodium bicarbonate 50 mg per 1 mlMagnesium trisilicate oral suspension|200mlG £1.65DT price = £1.65
ANTIFOAMING DRUGS
Simeticone
(Activated dimeticone)
lDRUG ACTIONSimeticone (activated dimeticone) is an antifoaming agent.
lINDICATIONS AND DOSE DENTINOX®
Colic|Wind pains
▶BY MOUTH
▶Child 1 month–1 year:2.5mL, to be taken with or after each feed; may be added to bottle feed; maximum 6doses per day
INFACOL® Colic|Wind pains
▶BY MOUTH
▶Child 1 month–1 year:0.5–1mL, to be taken before feeds lPRESCRIBING AND DISPENSING INFORMATION
DENTINOX®The brand nameDentinox®is also used for other preparations including teething gel.
lPATIENT AND CARER ADVICE
INFACOL®Patients or carers should be given advice on use of theInfacol®dropper.
lLESS SUITABLE FOR PRESCRIBING
INFACOL®Infacol®is less suitable for prescribing (evidence of benefit in infantile colic uncertain).
DENTINOX®Dentinox®colic drops are less suitable for prescribing (evidence of benefit in infantile colic uncertain).
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Infacol(Teva UK Ltd)
Simeticone 40 mg per 1 mlInfacol40mg/ml oral suspension sugar-free|50mlG £2.71DT price = £2.71
Oral drops
▶Dentinox Infant(Dendron Ltd)
Simeticone 8.4 mg per 1 mlDentinox Infant colic drops|100 mlG£1.73
Combinations available:Co-simalcite,p.68
.
Simeticone with aluminium hydroxide and magnesium hydroxide,p.694.2 Gastric and duodenal
Test forHelicobacter pylori
13C-Urea breath test kits are available for the diagnosis of gastro-duodenal infection withHelicobacter pylori. The test involves collection of breath samples before and after ingestion of an oral solution of13C-urea; the samples are sent for analysis by an appropriate laboratory. The test should not be performed within4weeks of treatment with an antibacterial or within2weeks of treatment with an antisecretory drug. A specific13C-urea breath test kit for children is available (Helicobacter Test INFAI for children of the age3–11®). However, the appropriateness of testing for H. pyloriinfection in children has not been established.
NSAID-associated ulcers
Gastro-intestinal bleeding and ulceration can occur with NSAID use. The risk of serious upper gastro-intestinal side-effects varies between individual NSAIDs. Whenever possible, the NSAID should bewithdrawnif an ulcer occurs.
Patients at high risk of developing gastro-intestinal complications with a NSAID include those aged over 65years, those with a history of peptic ulcer disease or serious gastro-intestinal complication, those taking other medicines that increase the risk of gastro-intestinal side-effects, or those with serious co-morbidity (e.g.
cardiovascular disease, diabetes, renal or hepatic impairment). In those at risk of ulceration, a proton pump inhibitor can be considered for protection against gastric and duodenal ulcers associated with non-selective NSAIDs; a H2 -receptor antagonist such as ranitidine p.74given at twice the usual dose or misoprostol p.75are alternatives. Colic and diarrhoea may limit the dose of misoprostol. Its use is most appropriate for the frail or very elderly from whom NSAIDs cannot be withdrawn. A combination of a cyclo-oxygenase-2selective inhibitor with a proton pump inhibitor may be more appropriate for those with a history of upper gastro-intestinal bleeding or3or more risk factors for gastro-intestinal ulceration, but see NSAIDs and Cardiovascular Events.
NSAID use andH. pyloriinfection are independent risk factors for gastro-intestinal bleeding and ulceration. In patients already taking a NSAID, eradication ofH. pyloriis unlikely to reduce the risk of NSAID-induced bleeding or ulceration. However, in patients with dyspepsia or a history of gastric or duodenal ulcer, who areH. pyloripositive, and who are about to start long-term treatment with a non-selective NSAID, eradication ofH. pylorimay reduce the overall risk of ulceration.
In a patient who has developed an ulcer, if theNSAID can be discontinued, a proton pump inhibitor usually produces the most rapid healing; alternatively, the ulcer can be treated with a H2-receptor antagonist or misoprostol. On healing, patients should be tested forH. pyloriand given
eradication therapy ifH. pyloriis present (see also Test for Helicobacter pylori).
Iftreatment with a non-selective NSAID needs to continue, the following options are suitable:
.Treat ulcer with a proton pump inhibitor and on healing continue the proton pump inhibitor (dose not normally reduced because asymptomatic ulcer recurrence may occur);
.Treat ulcer with a proton pump inhibitor and on healing switch to misoprostol for maintenance therapy (colic and diarrhoea may limit the dose of misoprostol);
.Treat ulcer with a proton pump inhibitor and switch non-selective NSAID to a cyclo-oxygenase-2selective inhibitor, but see NSAIDs and Cardiovascular Events; on healing, continuation of the proton pump inhibitor in patients with a history of upper gastro-intestinal bleeding may provide further protection against recurrence.
Iftreatment with a cyclo-oxygenase-2selective inhibitor needs to continue,treat ulcer with a proton pump inhibitor;
on healing continuation of the proton pump inhibitor in patients with a history of upper gastro-intestinal bleeding may provide further protection against recurrence.
GASTROPROTECTIVE COMPLEXES AND CHELATORS
Chelates and complexes
Overview
Sucralfate below may act by protecting the mucosa from acid-pepsin attack in gastric and duodenal ulcers. It is a complex of aluminium hydroxide and sulfated sucrose but has minimal antacid properties.
Sucralfate
lINDICATIONS AND DOSE
Benign gastric ulceration|Benign duodenal ulceration
▶BY MOUTH
▶Child 15–17 years:2g twice daily, dose to be taken on rising and at bedtime, alternatively1g4times a day for 4–6weeks, or in resistant cases up to12weeks, dose to be taken1hour before meals and at bedtime;
maximum8g per day
▶Adult:2g twice daily, dose to be taken on rising and at bedtime, alternatively1g4times a day for4–6weeks, or in resistant cases up to12weeks, dose to be taken 1hour before meals and at bedtime; maximum8g per
day continued
→
Recommended regimens forHelicobacter pylorieradication in adults
Acid suppressant Antibacterial
Price for7-day course Amoxicillin Clarithromycin Metronidazole
Esomeprazole20mg twice daily
1g twice daily
—
500mg twice daily 250mg twice daily
— 400mg twice daily
£6.63
£4.30 Lansoprazole30mg
twice daily
1g twice daily 1g twice daily
—
500mg twice daily
— 250mg twice daily
— 400mg twice daily 400mg twice daily
£5.52
£3.70
£3.19 Omeprazole20mg twice
daily
1g twice daily 500mg3times a day
—
500mg twice daily
— 250mg twice daily
— 400mg3times a day
400mg twice daily
£5.36
£3.40
£3.03 Pantoprazole40mg
twice daily
1g twice daily
—
500mg twice daily
250mg twice daily —
400mg twice daily
£5.48
£3.15 Rabeprazole sodium
20mg twice daily
1g twice daily
—
500mg twice daily 250mg twice daily
— 400mg twice daily
£6.04
£3.71
BNF74
Gastric and duodenal ulceration 71
Gastro-intestinalsystem
1
Chronic gastritis
▶BY MOUTH
▶Adult:2g twice daily, dose to be taken on rising and at bedtime, alternatively1g4times a day for4–6weeks or in resistant cases up to12weeks, dose to be taken 1hour before meals and at bedtime; maximum8g per day
Prophylaxis of stress ulceration in child under intensive care
▶BY MOUTH
▶Child 15–17 years:1g6times a day; maximum8g per day
Prophylaxis of stress ulceration
▶BY MOUTH
▶Adult:1g6times a day; maximum8g per day lUNLICENSED USE
Not licensed for use in children under15years. Tablets not licensed for prophylaxis of stress ulceration.
lCAUTIONSPatients under intensive care (Important:
reports of bezoar formation) CAUTIONS, FURTHER INFORMATION
▶Bezoar formationFollowing reports of bezoar formation associated with sucralfate, caution is advised in seriously ill patients, especially those receiving concomitant enteral feeds or those with predisposing conditions such as delayed gastric emptying.
lINTERACTIONS→Appendix1: sucralfate lSIDE-EFFECTS
▶Common or very commonConstipation
▶UncommonBack pain
.
bezoar formation.
diarrhoea.
dizziness
.
drowsiness.
dry mouth.
eadache.
flatulence.
gastric discomfort
.
indigestion.
nausea.
rashlPREGNANCYNo evidence of harm; absorption from gastro-intestinal tract negligible.
lBREAST FEEDINGAmount probably too small to be harmful.
lRENAL IMPAIRMENT Use with caution; aluminium is absorbed and may accumulate.
lDIRECTIONS FOR ADMINISTRATIONAdministration of sucralfate and enteral feeds should be separated by1hour and for administration bymouth, sucralfate should be given1hour before meals.Oral suspensionblocks fine-bore feeding tubes. Crushedtabletsmay be dispersed in water.
lPRESCRIBING AND DISPENSING INFORMATIONFlavours of oral liquid formulations may include aniseed and caramel.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: tablet, oral suspension
Tablet
CAUTIONARY AND ADVISORY LABELS5
▶Sucralfate (Non-proprietary)
Sucralfate 1 gramSulcrate1g tablets|100tablet no price available Carafate1g tablets|100tablet no price available
H2-RECEPTOR ANTAGONISTS
H
2-receptor antagonists
Overview
Histamine H2-receptor antagonistshealgastric and duodenal ulcersby reducing gastric acid output as a result of histamine H2-receptor blockade; they are also used to relieve symptoms ofgastro-oesophageal reflux disease. H2-receptor antagonists should not normally be used forZollinger-Ellison syndromebecause proton pump inhibitors are more effective.
Maintenance treatment with low doses for the prevention of peptic ulcer disease has largely been replaced inHelicobacter pyloripositive patients by eradication regimens.
In adults, H2-receptor antagonists are used for the treatment offunctional dyspepsiaand may be used for the treatment ofuninvestigated dyspepsiawithout alarm features.
H2-receptor antagonist therapy can promote healing of NSAID-associated ulcers (particularly duodenal).
Treatment with a H2-receptor antagonist has not been shown to be beneficial in haematemesis and melaena, but prophylactic use reduces the frequency of bleeding from gastroduodenal erosions in hepatic coma, and possibly in other conditions requiring intensive care. H2- receptor antagonists also reduce the risk ofacid aspirationin obstetric patients at delivery (Mendelson’s syndrome).
H
2-receptor antagonists
flCAUTIONSSigns and symptoms of gastric cancer (in adults)
CAUTIONS, FURTHER INFORMATION
▶Gastric cancer
▶In adultsH2-receptor antagonists might mask symptoms of gastric cancer; particular care is required in patients presenting with‘alarm features’in such cases gastric malignancy should be ruled out before treatment.
lSIDE-EFFECTS
▶Common or very commonDiarrhoea
.
dizziness.
headache▶UncommonErythema multiforme
.
rash.
toxic epidermal necrolysis▶RareArthralgia
.
blood disorders.
bradycardia.
cholestatic jaundice.
confusion.
depression.
hallucinations.
hepatitis.
leucopenia.
myalgia.
pancytopenia.
psychiatric reactions.
thrombocytopenia▶Frequency not knownGynaecomastia
.
impotence SIDE-EFFECTS, FURTHER INFORMATIONPsychiatric reactions, including confusion, depression, and hallucinations occur particularly in the elderly or the very ill.
eiiiFabovei
Cimetidine
lINDICATIONS AND DOSE Benign duodenal ulceration
▶BY MOUTH
▶Adult:400mg twice daily for at least4weeks, to be taken with breakfast and at night, alternatively800mg once daily for at least4weeks, to be taken at night;
increased if necessary up to400mg4times a day;
maintenance400mg once daily, to be taken at night, alternatively maintenance400mg twice daily, to be taken in the morning and at night
Benign gastric ulceration
▶BY MOUTH
▶Adult:400mg twice daily for6weeks, to be taken with breakfast and at night, alternatively800mg daily for 6weeks, to be taken at night; increased if necessary up to400mg4times a day; maintenance400mg once daily, to be taken at night, alternatively maintenance 400mg twice daily, to be taken in the morning and at night
NSAID-associated ulceration
▶BY MOUTH
▶Adult:400mg twice daily for8weeks, to be taken with breakfast and at night, alternatively800mg daily for 8weeks, to be taken at night; increased if necessary up to400mg4times a day; maintenance400mg daily, to be taken at night, alternatively maintenance400mg twice daily, to be taken in the morning and at night
72 Disorders of gastric acid and ulceration
BNF74Gastro-intestinalsystem
1
Reflux oesophagitis
▶BY MOUTH
▶Adult:400mg4times a day for4–8weeks Prophylaxis of stress ulceration
▶BY MOUTH
▶Adult:200–400mg every4–6hours Gastric acid reduction in obstetrics
▶BY MOUTH
▶Adult:Initially400mg, to be administered at start of labour, then increased if necessary up to400mg every 4hours, do not use syrup in prophylaxis of acid aspiration; maximum2.4g per day
Gastric acid reduction during surgical procedures
▶BY MOUTH
▶Adult:400mg, to be given90–120minutes before induction of general anaesthesia
Short-bowel syndrome
▶BY MOUTH
▶Adult:400mg twice daily, adjusted according to response, to be taken with breakfast and at bedtime To reduce degradation of pancreatic enzyme supplements
▶BY MOUTH
▶Adult:0.8–1.6g daily in4divided doses, dose to be taken1–1½ hours before meals
lINTERACTIONS→Appendix1: H2receptor antagonists lSIDE-EFFECTS
▶Common or very commonMalaise
▶UncommonTachycardia
▶RareInterstitial nephritis
▶Very rareAlopecia
.
galactorrhoea.
pancreatitis.
vasculitis lPREGNANCYManufacturer advises avoid unless essential.lBREAST FEEDINGSignificant amount present in milk—not known to be harmful but manufacturer advises avoid.
lHEPATIC IMPAIRMENTReduce dose. Increased risk of confusion.
lRENAL IMPAIRMENTReduce dose to200mg4times daily if eGFR30–50mL/minute/1.73m2. Reduce dose to200mg 3times daily if eGFR15–30mL/minute/1.73m2. Reduce dose to200mg twice daily if eGFR less than
15mL/minute/1.73m2. Occasional risk of confusion.
lEXCEPTIONS TO LEGAL CATEGORYCimetidine can be sold to the public for adults and children over16years (provided packs do not contain more than2weeks’supply) for the short-term symptomatic relief of heartburn, dyspepsia, and hyperacidity (max. single dose200mg, max. daily dose800mg), and for the prophylactic management of nocturnal heartburn (single night-time dose100mg).
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension
Oral solution
EXCIPIENTS:May contain Propylene glycol
▶Cimetidine (Non-proprietary)
Cimetidine 40 mg per 1 mlCimetidine200mg/5ml oral solution sugar free sugar-free|300mlP £14.24–£14.25DT price = £14.25
▶Tagamet(Essential Pharma Ltd)
Cimetidine 40 mg per 1 mlTagamet200mg/5ml syrup|600 mlP £28.49DT price = £28.49
Tablet
▶Cimetidine (Non-proprietary)
Cimetidine 200 mgCimetidine200mg tablets|60tabletP
£45.59|120tabletP£120.00
Cimetidine 400 mgCimetidine400mg tablets|60tabletP
£120.00DT price = £15.31
Cimetidine 800 mgCimetidine800mg tablets|30tabletPno price available DT price = £9.09
▶Tagamet(Chemidex Pharma Ltd)
Cimetidine 200 mgTagamet200mg tablets|120tabletP
£19.58
Cimetidine 400 mgTagamet400mg tablets|60tabletP
£22.62DT price = £15.31
Cimetidine 800 mgTagamet800mg tablets|30tabletP
£22.62DT price = £9.09
eiiiFi72
Famotidine
lINDICATIONS AND DOSE
Treatment of benign gastric and duodenal ulceration
▶BY MOUTH
▶Adult:40mg once daily for4–8weeks, dose to be taken at night
Maintenance treatment of duodenal ulceration
▶BY MOUTH
▶Adult:20mg once daily, dose to be taken at night Reflux oesophagitis
▶BY MOUTH
▶Adult:20–40mg twice daily for6–12weeks;
maintenance20mg twice daily
lINTERACTIONS→Appendix1: H2receptor antagonists lSIDE-EFFECTS
▶Common or very commonConstipation
▶UncommonFatigue
.
vomiting.
anorexia.
dry mouth.
flatulence
.
nausea.
taste disorders▶Very rareChest tightness
.
interstitial pneumonia.
paraesthesia
.
seizureslPREGNANCYManufacturer advises avoid unless potential benefit outweighs risk.
lBREAST FEEDINGPresent in milk—not known to be harmful but manufacturer advises avoid.
lRENAL IMPAIRMENTUse normal dose every36–48hours or use half normal dose if eGFR less than
50mL/minute/1.73m2. Seizures reported very rarely.
lEXCEPTIONS TO LEGAL CATEGORYFamotidine can be sold to the public for adults and children over16years (provided packs do not contain more than2weeks’supply) for the short-term symptomatic relief of heartburn, dyspepsia, and hyperacidity, and for the prevention of these symptoms when associated with consumption of food or drink including when they cause sleep disturbance (max. single dose10mg, max. daily dose20mg).
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Tablet
▶Famotidine (Non-proprietary)
Famotidine 20 mgFamotidine20mg tablets|28tabletP
£22.00DT price = £21.79
Famotidine 40 mgFamotidine40mg tablets|28tabletP
£39.00DT price = £38.98
eiiiFi72
Nizatidine
lINDICATIONS AND DOSE
Benign gastric, duodenal or NSAID-associated ulceration
▶BY MOUTH
▶Adult:300mg once daily for4–8weeks, dose to be taken in the evening, alternatively150mg twice daily for4–8weeks; maintenance150mg once daily, dose to be taken at night
Gastro-oesophageal reflux disease
▶BY MOUTH
▶Adult:150–300mg twice daily for up to12weeks lINTERACTIONS→Appendix1: H2receptor antagonists
BNF74
Gastric and duodenal ulceration 73
Gastro-intestinalsystem
1
lSIDE-EFFECTS
▶Common or very commonSweating
▶RareFever
.
hyperuricaemia.
nausea.
vasculitis lPREGNANCYManufacturer advises avoid unless essential.lBREAST FEEDINGAmount too small to be harmful.
lHEPATIC IMPAIRMENTManufacturer advises caution.
lRENAL IMPAIRMENT Use half normal dose if eGFR 20–50mL/minute/1.73m2. Use one-quarter normal dose if eGFR less than20mL/minute/1.73m2.
lEXCEPTIONS TO LEGAL CATEGORYNizatidine can be sold to the public for the prevention and treatment of symptoms of food-related heartburn and meal-induced indigestion in adults and children over16years; max. single dose75mg, max. daily dose150mg for max.14days.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension, oral solution Capsule
▶Nizatidine (Non-proprietary)
Nizatidine 150 mgNizatidine150mg capsules|30capsuleP
£12.20DT price = £3.82
Nizatidine 300 mgNizatidine300mg capsules|30capsuleP
£15.43DT price = £15.43
eiiiFi72
Ranitidine
lINDICATIONS AND DOSE
Benign gastric ulceration|Duodenal ulceration
▶BY MOUTH
▶Child 1–5 months:1mg/kg3times a day (max. per dose 3mg/kg3times a day)
▶Child 6 months–2 years:2–4mg/kg twice daily
▶Child 3–11 years:2–4mg/kg twice daily (max. per dose 150mg)
▶Child 12–17 years:150mg twice daily, alternatively 300mg once daily, dose to be taken at night
▶Adult:150mg twice daily for4–8weeks, alternatively 300mg once daily for4–8weeks, dose to be taken at night
Chronic episodic dyspepsia
▶BY MOUTH
▶Adult:150mg twice daily for6weeks, alternatively 300mg once daily for6weeks, dose to be taken at night NSAID-associated gastric ulceration
▶BY MOUTH
▶Adult:150mg twice daily for up to8weeks, alternatively300mg once daily for up to8weeks, dose to be taken at night
NSAID-associated duodenal ulcer
▶BY MOUTH
▶Adult:300mg twice daily for4weeks, to achieve a higher healing rate
Prophylaxis of NSAID-associated gastric ulcer| Prophylaxis of NSAID-associated duodenal ulcer
▶BY MOUTH
▶Adult:300mg twice daily Gastro-oesophageal reflux disease
▶BY MOUTH
▶Adult:150mg twice daily for up to8weeks or if necessary12weeks, alternatively300mg once daily for up to8weeks or if necessary12weeks, dose to be taken at night
Moderate to severe gastro-oesophageal reflux disease
▶BY MOUTH
▶Adult:600mg daily in2–4divided doses for up to 12weeks
Long-term treatment of healed gastro-oesophageal reflux disease
▶BY MOUTH
▶Adult:150mg twice daily
Gastric acid reduction (prophylaxis of acid aspiration) in obstetrics
▶BY MOUTH
▶Adult:150mg, dose to be given at onset of labour, then 150mg every6hours
Gastric acid reduction (prophylaxis of acid aspiration) in surgical procedures
▶INITIALLY BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS INJECTION
▶Adult:50mg, to be given45–60minutes before induction of anaesthesia, intravenous injection diluted to20mL and given over at least2minutes,
alternatively (by mouth)150mg, to be given2hours before induction of anaesthesia and also when possible on the preceding evening
Prophylaxis of stress ulceration
▶INITIALLY BY SLOW INTRAVENOUS INJECTION
▶Adult:50mg every8hours, dose to be diluted to20mL and given over at least2minutes, then (by mouth) 150mg twice daily, may be given when oral feeding commences
Reflux oesophagitis and other conditions where gastric acid reduction is beneficial
▶BY MOUTH
▶Child 1–5 months:1mg/kg3times a day (max. per dose 3mg/kg3times a day)
▶Child 6 months–2 years:2–4mg/kg twice daily
▶Child 3–11 years:2–4mg/kg twice daily (max. per dose 150mg); increased to up to5mg/kg twice daily (max.
per dose300mg), dose increase for severe gastro-oesophageal disease
▶Child 12–17 years:150mg twice daily, alternatively 300mg once daily, dose to be taken at night, then increased if necessary to300mg twice daily for up to 12weeks in moderate to severe gastro-oesophageal reflux disease, alternatively increased if necessary to 150mg4times a day for up to12weeks in moderate to severe gastro-oesophageal reflux disease
Conditions where reduction of gastric acidity is beneficial and oral route not available
▶BY INTRAMUSCULAR INJECTION
▶Adult:50mg every6–8hours
▶BY SLOW INTRAVENOUS INJECTION
▶Adult:50mg, dose to be diluted to20mL and given over at least2minutes; may be repeated every 6–8hours
lUNLICENSED USE
Oralpreparations not licensed for use in children under 3years.Injectionnot licensed for use in children under 6months. Doses given for prophylaxis of NSAID-associated gastric or duodenal ulcer, and prophylaxis of stress ulceration, are not licensed.
lINTERACTIONS→Appendix1: H2receptor antagonists lSIDE-EFFECTS
▶UncommonBlurred vision
▶Frequency not knownAlopecia
.
interstitial nephritis.
involuntary movement disorders
.
pancreatitis lPREGNANCYManufacturer advises avoid unless essential,but not known to be harmful.
lBREAST FEEDINGSignificant amount present in milk, but not known to be harmful.
lRENAL IMPAIRMENT
▶In adultsUse half normal dose if eGFR less than 50mL/minute/1.73m2.
74 Disorders of gastric acid and ulceration
BNF74Gastro-intestinalsystem