Midler mod mavesyrerelaterede forstyrrelser (A02)

Rekommandation

Protonpumpe-hæmmere (PPI’er) er som udgangspunkt 1. valg til behandling af:

• Ulcus
• Gastroøsofageal reflukssygdom (GERD)
• Profylakse mod NSAID-induceret ulcus

H2-receptor antagonister kan anbefales ved:

• Symptomstyret behandling af lettere (ikke-erosiv) reflukssygdom
• Symptombehandling ved dyspepsi eller reflukssymptomer i ventetiden inden endoskopi.

Præparater markeret med * har ikke tilskud.

Rekommanderet (med ækvieffektive doser)

PPI'er

*Esomeprazol   20 mg

Lanzoprazol    30 mg

Omeprazol      20 mg

Pantoprazol    40 mg

*Rabeprazol     20 mg

H2-receptor antagonister 

Famotidin  40 mg

Nizatidin  300 mg

*Ranitidin  300 mg

Ikke rekommanderet

Prostaglandiner 
*Misoprostol

Baggrundsnotat

LægemidlerForfattere

Referencer

Lægemidler

Inddeles i antacida (A02A), H2-receptor antagonister (A02BA), prostaglandiner (A02BB), protonpumpehæmmere (PPI’er) (A02BC) samt sukralfat og alginsyre (A02BX) til behandling af ulcus og gastroøsofageal reflukssygdom (GERD).
Antacida, sukralfat og alginsyre behandles ikke i dette notat.

Protonpumpehæmmere

PPI’er er det primære valg ti lbehandling af ulcera og GERD baseret på utallige undersøgelser, der viser en lidt hurtigere smertestillende virkning og lidt bedre opheling end med H2-receptor antagonister (1, 2).

Kliniske endepunkts-studier viser ingen væsentlig forskel mellem de forskellige PPI’er anvendt i de neden for angivne doser. Det gælder både for GERD (3, 4, 5, 6, 7, 8), ulcus (9, 10, 11, 12, 13) og eradikationsbehandling (17, 18, 19). Ved behov for profylakse i forbindelse med NSAID-behandling kan både PPI’er og H2-receptor antagonister anvendes, men PPI behandling har større effekt (14, 15). Hverken PPI eller H2-receptor antagonister beskytter den nedre gastrointestinalkanal mod NSAID -inducerede skader (16).

Der kan være marginale forskelle på de enkelte midlers registrerede indikationer, men dette tillægges ikke afgørende klinisk betydning. Alle midlerne regnes for ækvieffektive til alle indikationer, også symptomstyret (p.n.) behandling af GERD.

Med udgangspunkt i de kliniske studier kan følgende doser anses for ækvieffektive:

Esomeprazol findes ikke i 10 mg.
I de fleste studier med esomeprazol er anvendt 40 mg. Esomeprazol 40 mg er vist marginalt mere effektiv end 20 mg med hensyn til ulcusopheling og smertelindring (primært ved Los Angeles grad C og D), med ved ukompliceret anvendelse i almen praksis er der sjældent behov for doser over 20 mg.

H2-receptor antagonister (A02BA)

Ved behov for profylakse i forbindelse med NSAID-behandling kan både PPI’er og H2-receptor antagonister anvendes, men PPI behandling har større effekt (14, 15).

Markedets H2-receptor antagonister anses for at have samme maksimaleffekt, men forskellig potens til både GERD (21, 22, 23) og ulcus (24, 25, 26, 27, 28, 29, 30, 31).

Rekommandationen for H2-receptor antagonisterne bliver derfor med ækvieffektive doser:

Prostaglandiner

Der foreligger ikke dokumentation fra randomiserede studier for at misprostol 200 mikrog x 2 reducerer risikoen for alvorlige GI-hændelser. Det er dokumenteret, at 400 mikorg x 2 har nogen effekt, men giver også forholdsvis hyppigt diarré som bivirkning (32). Der er endvidere ikke fundet evidens for en særlig fordel af prostaglandiner mht. resuktion af nedre gastrotoxicitet.

Forfattere

Revideret den 10. februar 2008 af IRF med deltagelse af de eksterne specialister:

Jan Fallingborg - Dansk Gastroenterologisk Selskab
Peter Matzen - Dansk Gastroenterologisk Selskab
Lars Kristian Munck - Dansk Gastroenterologisk Selskab
Dorte Jarbøl - Dansk Selskab For Almen Medicin
Lars Bo Svendsen - Dansk Kirurgisk selskab

Referencer

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3. Sharma VK, Leontiadis GI, Howden CW. Meta-analysis of randomized controlled trials comparing standard clinical doses of omeprazole and lansoprazole in erosive oesophagitis. Alim Pharmacol Ther 2001; 15: 227-31.
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6. Delchier, JC, Cohen G & Humphries TJ. Rabeprazole 20 mg once daily or 10 mg twice daily, is equivalent to omeprazole, 20 mg once daily, in the healing of erosive gastrooesophageal reflux disease. Scand J Gastroenterol 2000; 35: 1245-50.
7. Edwards SJ, Lind T & Lundell L. Systematic review of proton pump inhibitors for the acute treatment o f reflux oesophagitis. Al pharm Ther 2001; 15: 1729-36.
8. Castell Dom Kahrilas PJ, Richter JE et al. Esomeprazole (40 mg) compared with lansoprazole (30 mg) in the treatment of erosive esophagitis. Am J Gastroenterol 2002; 97: 575-83.
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Institut for Rationel Farmakoterapi, 10. februar 2009

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