“I’ve been on these omeprazole for years — I just want a repeat, not a lecture”

A long-standing PPI on repeat is a REVIEW opportunity, never a rubber stamp: establish the original indication, current control and whether step-down/stop is appropriate, and remember indefinite PPIs carry real considerations (hypomagnesaemia, B12, fracture risk, enteric infection, rebound). But the FIRST duty before treating chronic "reflux" as benign is to actively screen the NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026) upper-GI ALARM features — dysphagia, unintentional weight loss, upper abdominal pain/mass, persistent vomiting, GI bleeding, iron-deficiency anaemia, treatment resistance — which patients frequently minimise. NICE NG12 thresholds (1.2.1, amended in the 2025 update): refer using a suspected cancer pathway referral for oesophageal cancer people with DYSPHAGIA at ANY age, or aged 55+ with WEIGHT LOSS plus upper abdominal pain/reflux/dyspepsia (this replaced urgent direct-access OGD); consider non-urgent direct-access OGD for haematemesis at any age and, only at 55 and over, for treatment-resistant dyspepsia, upper abdominal pain with low Hb, or raised platelets with nausea or vomiting. New dysphagia plus weight loss converts a routine repeat into a suspected cancer pathway referral regardless of what the patient came for. Only in the ABSENCE of alarm features does the standard pathway apply: lifestyle, PPI step-down to lowest effective/PRN, and H. pylori test-and-treat (off PPI). The hidden agenda is a busy, self-reliant man minimising alarm symptoms under work pressure; the skill is to insist gently on the review, elicit the downplayed features, refer urgently with honesty (not panic), support his work needs, and safety-net.