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
Elective surgery
Continue.
Patients who take ‘when required’ lansoprazole should be advised to take a dose of their usual medication on the morning of surgery.
EXCEPT: Investigations for H. pylori – stop 2 weeks prior to investigation
Emergency surgery
Continue.
Perioperative considerations
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.
NB: Lansoprazole is not licensed for prophylaxis of aspiration in relation to anaesthesia.
Post-operative advice
Patients undergoing anti-reflux surgery or total gastrectomy
Review continued need for lansoprazole therapy following surgery. Consider long-term implications of lansoprazole use if continued – see Further information.
Use of post-operative non-steroidal anti-inflammatory drugs (NSAIDs)
Consider prophylaxis with lansoprazole for patients commenced on NSAIDs for post-operative pain relief, especially in those that have increased risk factors for gastrointestinal ulceration. Use the lowest possible dose. Discontinue lansoprazole as soon as patient stops NSAID treatment.
Histamine-2 Receptor Antagonists are an alternative in those patients where PPIs are unsuitable.
Interactions with common anaesthetic agents
None.
Interactions with other common medicines used in the perioperative period
Antimicrobials
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. pylori. Given the wide use of H. pylori regimens containing these drugs it seems unlikely that the interaction is common.
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).
Hypomagnesaemia
Lansoprazole can cause hypomagnesaemia, which might be additive with the magnesium-lowering effects of aminoglycosides (e.g. gentamicin). The risk is highest with those who have been on long-term PPI therapy (usually > 1 year). The MHRA have advised that consideration should be given to monitoring magnesium levels. In patients who develop hypomagnesaemia, oral and parenteral magnesium supplements might not be as effective as anticipated – stopping the lansoprazole, where possible, might be necessary.
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 periodically. Long-term complications of PPI use include electrolyte disturbances (especially hypomagnesaemia), increased risk of fractures and gastro-intestinal infections (including CDI) – 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, CDI.
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 suppression. See also Histamine H2-receptor antagonists drug records.
References
NICE Clinical Guideline [CG184]. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. www.nice.org.uk. Accessed 22nd June 2019, last updated November 2014
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 22nd June 2019]
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 22nd June 2019]
Omeprazole. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 22nd June 2019]
UK Medicines Information (UKMi) Medicines Q&As. Clostridium difficile infection – is use of proton pump inhibitors a risk factor? www.sps.nhs.uk [Accessed on 27th June 2019]. Date updated: November 2015
Medscape. Acid Suppression in the Perioperative Setting: Acid-Related Pulmonary Complications. www.medscape.org [Accessed 22nd June 2019]
Aspiration syndromes (Gastrointestinal Drugs – Management of Gastrointestinal Disorders). In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 22nd June 2019]