PPI background

SC use of PPIs in palliative care patients

Patients with palliative care needs may require treatment to suppress gastric acid secretions, for example in the management of malignant bowel obstruction, gastrointestinal bleeding (treatment and prophylaxis), dyspepsia, and reflux symptoms. These patients commonly have swallowing difficulties, therefore necessitating alternate routes to administer medications. Enteral tubes and intravenous cannula can be uncomfortable, invasive, and difficult to maintain long term in community settings; consequently, many medications are given subcutaneously.

The use of parenteral ranitidine (a H2 Receptor Antagonist) had been popular for its use in palliative care patients with malignant bowel obstruction where oral route was not an option. Since 2019, though, the manufacture of ranitidine was stopped due to concerns around the drug’s safety profile. Famotidine, another H2 receptor antagonist, can also be administered subcutaneously, but this route is unlicensed and there is a paucity of evidence supporting this use. In contrast, PPIs are more readily available and, although their SC administration is also unlicensed, there are some published case reports and small case series which support their use, particularly esomeprazole, omeprazole, and pantoprazole. In addition, PPIs are more potent suppressors of gastric acid than H2 receptor antagonists, and are the preferred choice for treating un-investigated dyspepsia.

The choice of PPI will be influenced by numerous factors, including: drug availability, costing, side effect profile, as well as local guidance and formulary classifications.

All medication decisions should be on an individual patient basis and take into account likely risks, potential benefits, and patient wishes. Most often, stopping medications is the preferred option to switching route if the patient is unable to swallow.

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.