Correct dose of Omeprazole for treating acid reflux?

[Sisa]

My son's acid reflux continues to be pretty bad (refluxing 18x a day on average) despite taking max dose of omeprazole (losec mups)of 1mg/kg once a day. I have just read that paediatricians tend to under-dose this drug in babies as their metabolism works much faster than that of an adult. I know this medicine does not do anything for him as it is supposed to inhibit the acid-producing pumps from pumping out acid, but that is clearly not happening, as whenever I test the acidity of his belly (he is tube-fed), it tests as very acidic at PH 1.5 to 2.0. Is anyone's child on a higher/more frequent dose than this? One american website (Marci-kids) suggests that dissolving the tablet in water strips it off its protective coating (which should stay on until the drug reaches the intestines thus avoiding the acid in the stomach) and that the acid in the belly destroys the drug before it gets the chance to work, thus rendering it useless - and from what we are experiencing, this could be right. The Marci-kids website advocates the use of an omeprazole-based powder called Zegerid with in-built protective buffer but I understand this is not available in the UK - am I right?

Ok, my understanding of omeprazole is that it cannot be crushed and put down the tube no.
As an alternative we use ranitadine/ Zantac as this comes in liquid form.
Now i am not sure if it is licensed to use on paeds, but look it up or speak to the pharmacist.
Does he have a peg or ng tube?

i don't know either because when mine had reflux they weren't prescribing omeprazole routinely. I take it (40mg a day) and I have special gastro-acid resitant capsules so I wouldn't be surprised if taking out the powder wouldn't help as much iyswim.

ds used to take the capsules - but for babies you have to open up the capsule and dissolve the inside of it in soda bicarbonate - he used to vomit most of it out as soon as it got into his stomach, hence we asked for the tablets...

he has an NG tube, as he also has laryngomalacia and is unable to take in the required volumes of milk himself.

Ranitidine worked only for a while, he built up resistance to it.

oh poor lad. Has he seen a special paed gastroenterologist?

Sorry, no other suggestions in that case, What about speaking to the pharmacist at your chemist?
Does he not have a link nurse or regular consultant appointments?

Mups are fine to be dissolved in water they are formulated to be taken this way, unlike the traditional omeprazole (mups are tiny coated granules- NB you must NOT crush them before dissolving). BNF-C states a range of doses for children 700 micrograms/kg increased if necessary - 3mg/kg up to max 20mg once daily 1month-2yrs old. I would suggest speaking to your doctor again, however assuming your baby is under 2 yrs perhaps the doctor would be able to consider a dose increase if clinically appropriate. (Pharmacist)

Ah i see, allow to disolve because if you cant crush the granules they tend to block an ng tube very easily, especially a tiny baby one.
Its so annoying when that happens.
Does it not come in liquid form at all?
I have dissolved them in a touch of warm water befor now.
Ive only ever tend to give it IV i have to confess.

There is not a liquid, however I'm not sure if I recall the injection being given orally, however this would be unlicensed (as many paed drugs are and all drugs down ng's). I don't have the right text books on me to check atm, but will speak to the medicines information pharmacist/look in the right text book on monday.

thanks v much for the messages. We are going to see his paed gastroentologist and his regular paed in their joint clinic on Wednesday so I am trying to find out as much as poss before then.

ds is 7 mths old and weighs 7.8kg. Pipsy, thanks v much for checking your books, really appreciated. This is how i prepare the medicine - i dissolve the tablet in 10ml of cooled boiled water, then i stir it to help dissolve it and if there are any bits left i then crush them down so that the mixture is ok to go down ng tube - is it ok to crush it once its dissolved? Then i draw out 7.8ml and give it to him pretty much straight away, otherwise small capsules start forming, no good for sending down the tube...

IIRC there is similar form of the drug called Esomeprazole (Nexium) which is more effective in some patients than Omeprazole if omeprazole is not controlling the stomach acid.

Just something else that you might want to look into.

Hi Sisa, have checked the books at work today. They suggest MUPs are prone to blocking tubes of less than 8Fr bore however I still can't suggest crushing the bits that haven't dissolved as this will alter the effectiveness of the formulation. Books suggested that Alpharma and Dexcel brand of omeprazole tablets dissolve in water to make a milky suspension which will not block tube, I think this may possibly your best solution (you will need gp to prescribe this specific brand and speak to your community pharmacist to see if they can get this). Couldn't easily find info on using injection specifically via ng tube. There are also options of adding sodium bicarbonate to opened capsules but this sounds a faf! Re Esomeprazole- can't find much info on this in paeds and many trusts and PCTs won't allow it to be prescribed as this was a formulation bought out by astrazeneca when their patent was running out on omeprazole so additional benefits versus costs not really proven. Either the paediatric or medicines information pharmacist at your hospital may be able to help you further. Hope this helps, good luck on wednesday. Pipsy.

Hi Pipsy, thank you so much for this, extremely helpful! I will let you know tomorrow how we got on.

In the meantime I have been adding food thickener to the (uncrushed) medicine mix before sending down the tube - it makes it go down beautifully as it lubricates the tube and the undissolved bits don't stick together - I hope that this home invention of mine is not yet again rendering the medicine useless!

hi Pipsy, just to report back - ds had the appt with his Great Ormond St Hospital gastroentologist yesterday - he comes to our hospital once every 3mths to see the problematic children & to teach the local paediatricians, so there were 4 other doctors present at the appointment. We mentioned the problem we have with MUPS blocking the tube and the Alpharma & Dexcel brands - none of the 5 doctors have ever heard of them. Our pharmacist can get hold of either of them, but she suggested why dont we get a prescription for 'Omeprazole oral suspension' which they can order as a 'special', it will come ready made as a suspension from a supplier lab. She said that there is no brand name for it, at least not on their systems. When I mentioned this to the 5 doctors, 4 of them had no idea Omeprazole comes in this form, so they learned something new, and we now have a prescription for it in the pipeline. The one who new about it said it has no brand name as the lab would use any brand of the Omeprazole to make up the suspension. She also said that they tested the Omeprazole Losec Mups for sending down the tube and said that she would not send it down a tube smaller than 12 Fr. It was sad to see how far behind the doctors, even the good ones, are in the knowledge of the medicines. Another thing we learned from the gastroentologist is how the Proton Pump Inhibitor drugs work - he told us that of course the acidity of the stomach will remain very low, as, contrary to popular belief, the PPI's don't actually inhibit the pumps, they only reduce the volume of acid they pump out.

The doctors could not work out what causes ds to reflux, esp once we described the pattern of his reflux episodes, and were worried about his lack of progress so the poor thing will need to have an x-ray and a ph study and then depending on the results maybe even an endoscopy.

Thanks again for your help,

Silvia

Sisa
I really hope you get things sorted out for your lo. I am interested in what you have found out about omeprazole - my dS is 16 months and on omeprazole (10mg) and domperidone and ahs been since he was 8 months. He does not have an ng tube or anything, but has bad reflux. We have been trying to get him off the meds but so far without suuccessm although we have managed to cut two of the doses of domperidone. I am beginning to think he is not on a high enough dose of omeprazole because we are finding he is coughing and trying to clear his throat a lot at night and making gagging noises which are typical of him refluxing (but he hasn't done it sicne he was about 8 months). We are unsure whether to increase the dose or not, however back in May the paed did say in theory he could have up to 20mg. I am intersted to find out about not crushign the mups, we don't crush them but I do dissolve it in about 5ml of cold water and then stir it before tipping it into yoghurt or rice pudding or something - so I am no thinking that maybe this is destrying the action of the PPI. What do you think?

Sisa, I'm glad to hear you've had some progress with the treatment of your ds, it's also great that your pharmacist is able to get you the omeprazole special. I hope all goes well with your ds's further tests, best wishes, pipsy

Jen, manufacturer's advise omeprazole mups may be dissolved in water them mixed in small amount of fruit juice or yoghurt etc immediately before giving, so what you describe should be fine!

Hi Jen, none of the medicines my ds has been on so far have reduced the frequency of his reflux, but omeprazole at least keeps the acid under control so that he is not in pain whilst he is being fed and when vomiting. His dose was increased a couple of months ago because he started screaming in pain again, so if you think your lo's symptoms are coming back it may be time to check the dose with the paed - a phonecall should be enough.

Hi All,

I have been following this discussion and was so relieved to find other mums out there who have experience with little refluxers. My little boy is now 16 months old and has been refluxing since he was a baby. He was undiagnosed until he was one years old and finally we got see a paed. He is now on omeprazole and domperidone. His condition worsened in May and that is when he was taken off the ranitidine and put on the omeprazole. Although there is a huge improvement in the number of vomits he still vomits almost daily and totally refuses to feed except for his fortini mutifibre drink. It's usually projectile too. We have asked our GP for the oral suspension and he has prescribed 20mg omeprazole in 10ml suspension, 2.5ml to be given daily. We are hoping that he can keep that down better will let you know how we get on. An improvement in his apetite would cheer me up no end since he weighs only 8.4kg

Sahara - this is an old thread but I've just seen your post. I think its important to be aware that omeprazole will not reduce the vomiting - it will just stop/ reduce the acidity so stop the pain the vomiting causes. Domperidone is supposed to stop / reduce the vomiting. How much domperidone is he having and when?

The omeprazole - my DS is 9kg and is on 5ml daily of the same suspension, but he is a lot younger than your DS. Are you still seeing the paediatrician?

Hello Owlingate,

Thanks for your post. Having just re-read my post I can see that it does seem to imply that I assume Omeprazole will stop vomiting.... oops. I am aware that it is just a proton pump inhibitor so reduces acid. I probably should have mentioned that his dose and frequency of domperidone was also increased. At the moment my son is on 3.5ml of Domperiodone 4 times a day and I am thinking that maybe he would benefit from 2 doses of the Omeprazole one in the morning and one at night. We don't see the paed again until Sept. I was pretty upset to find that in his last weighing he only put on 400g of weight in 6 weeks. His Paed seemed to think that it was good weight for a reflux toddler!!

I also forgot to mention that the omeprazole dose is according to weight and not age as far as I am aware, supposed to be 1mg/kg so he can have 10mg daily which was what his capsule dose was. We only got the suspension prescribed two days ago (because of difficulty giving capsule) and the prescription read 20mg/5ml suspension (not 20mg/10ml which was written in error), 2.5ml daily i.e he still gets 10mg daily.

Oh ok good I was thinking he was getting a low dose! My DS has 5ml daily of 20mg/10ml so they're on about the same dose. I asked the paed last time about doing two doses of omeprazole per day i.e. splitting the dose, he said it wouldn't work any better , it would weaken the effect. I think some docs say split the dose for children as they metabolise it quicker.

Your DS' domperidone dose sounds on the high end which is good, can't believe you're not seeing the paed until September when your DS doesn't actually eat!I suppose the theory is at least he's gaining. Have you seen any improvement recently? I'm told that all will grow out of it by 2 years? My DS1 had it but not so badly, he had grown out of it by 1 year old. How is your DS' development otherwies

I'm not familiar with the DS abbreviation by the way and I see a lot of Mumsnetters use it. I can tell that your referring to your baby but not sure if it's boy/girl. Anyway my little boy is a very active and always on the go. Usually won't sit still for a second. His development is not a concern thankfully! Has been walking by himself since 11 months and climbing stairs etc. His Domperidone is on the high end because he was unable to hold down any of his feeds and would gag at the site of food and even on an empty stomach. It just seemed to suddenly worsen recently with teething and his had a complete loss of appetite after that episode. Yes they seem to think that since he is gaining weight even though he is very underweight for his height that is somehow ok. It is very frustrating for us since we can't ever take him out for picnic's etc. I have been told that they do grow out of it but that is of little comfort right now.