dyspepsia new approaches to clinical management professor pali hungin professor of primary care and...
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Dyspepsia
New Approaches To Clinical Management
Professor Pali Hungin
Professor of Primary Care and General Practice
University of Durham
UK
Therapeutic Options
Patient Empowerment
Dyspepsia
Who should be investigated?
The role of H pylori – test and treat?
Therapies for dyspepsia
“Dyspepsia”
Gastro-oesophageal reflux disease: 60%+
Non-ulcer dyspepsia: ?20%+
Ulcer dyspepsia: 4%
Reflux disease more accurate on clinical grounds but gross overlap!!
Test and Treat
H pylori prevalence 40%, declining
Ulcer rate 4%, variable
A worthwhile gamble?
Non-ulcer dyspepsia: benefit 1:15 overall
Manageable dyspepsia = acid sensitive dyspepsia
Locke et al., Gastroenterology 1997;112:1448–56.
Pre
vale
nce
(%
)
25–34 35–44 45–54 55–64 65–74Age (years)
40
0
Women: at least weekly episodes
Men: at least weekly episodes
Prevalence of heartburn or acid regurgitation
Prevalence of heartburn or acid regurgitation
Prevalence of GERD by age and sex
800
100
200
300
400
500
600
700
900
12-24 24-44 45-64 64-74 Age group
FemalesMales
El-Serag & Sonnenberg, Gut 1997;41:594-9.
Pre
vale
nce
per
10,
000
po
pu
lati
on
Lagergren et al., N Engl J Med 1999;340:825–31.
Od
ds
rat
io
20
0None 1 2–3 >3 0 <12 12–20 >20
Frequency
Chronicity
1
5.1
6.3
16.7
1
5.2
16.4
7.5
Heartburn episodes/week Duration of symptoms (years)
Frequency and duration of symptoms
Heartburn as a risk factor for oesophageal adenocarcinomaHeartburn as a risk factor for oesophageal adenocarcinoma
0
500
1000
1500
2000
2500
3000
3500
4000
79 84 89 94 97
Mo
rtal
ity
Year
Office of National Statistics, 1999.
Mortality due to oesophageal adenocarcinoma in England and Wales
Mortality due to oesophageal adenocarcinoma in England and Wales
Typical symptomsTypical symptoms(Heartburn/regurgitation)(Heartburn/regurgitation)
Atypical symptomsAtypical symptoms ComplicationsComplications
With oesophagitis
Without oesophagitis
Chest pain(visceral
hyperalgesia)
Asthma, chronic cough,
wheezing
Hoarseness(‘reflux
laryngitis’)
Oesophageal erosions
and/or ulcers
Stricture
Barrett’s oesophagus
Oesophageal adenocarcinomaDental erosions
Nathoo, Int J Clin Pract 2001;55:465–9.
Range of presentations of GERDRange of presentations of GERD
“If I had known I was going to live this long I would have
taken better care of myself!”
George Burns at age 95
GERD in the older patient.Findings
Presence of heartburn does not correlate as well with acid exposure
Poorer correlation with pH testing and endoscopic appearances
More severe pathology despite equal or less severe/frequent symptoms than younger patients
Oesophageal stricture
Barrett’s oesophagus
Oesophageal adenocarcinoma
Anaemia
Savary-Miller Grade IV and above
Nathoo, Int J Clin Pract 2001;55:465–9.
Consequences of severe and prolonged GERD
Consequences of severe and prolonged GERD
GERD: presentation in the older patient
Common
Often less severe and less frequent symptoms
Dysphagia, vomiting and anaemia more common
Medications associated with GERD
Affecting LES pressure: Anticholinergics, theophyllines, sedatives, calcium channel blockers
Direct injury to oesophagus:Potassium tablets, doxycycline, ferrous sulphate, alendronate, NSAIDs
Jasperson. Drug Safety 2002.
ManagementBasic principles
1. Effective symptom relief
2. Earlier detection of serious lesions
3. Prevention of complications
The earlier detection of lesions
Early investigation
New presentations
Alteration in symptoms or response to therapy
Alarm symptoms
PPIs H2RAs
Lifestyle modifications
Prokinetic motility agents
Antacids and alginates
Surgery
Hatlebakk & Berstad, Clin Pharmacokinet 1996;31:386–406.
Approaches
Treatment optionsTreatment options
Alginates…
Superior to antacids
Are not antacids!
Do not interact adversely with PPIs
Fast relief
Can be used for “topping up”
Acid suppression therapy
1. Empirical therapy or only post-investigation?
2. H2-receptor blockers
3. PPIs
Old patients may require greater acid suppression to heal oesophagitis
Fast relief but longer duration of action than antacids
Associated with more drug interactions
H2RAs are generally not as effective as PPIs for symptom relief or healing
Are available as a combination with antacid: quick action and PRN use possible
de Caestecker, BMJ 2001;323:736–9.Sonnenberg, Pharmacoeconomics 2000;17:391–401.
H2-receptor antagonists (H2RAs)H2-receptor antagonists (H2RAs)
Risk ratio.012003 1 83.3135
Study % Weight Risk ratio (95% CI)
0.26 (0.15,0.46) Bardhan 1995 5.0 0.33 (0.16,0.69) Klinkenberg-Knol 1987 3.3 0.42 (0.28,0.62) Havelund 1988* 7.1 0.48 (0.33,0.69) Sandmark 1988 7.8 0.59 (0.48,0.73) Bate 1990 11.1 0.60 (0.37,0.98) Dehn 1990* 5.9 0.63 (0.42,0.94) Bianchi Porro 1992 7.1 0.72 (0.54,0.95) Koop 1995 9.5 0.61 (0.38,0.99) IROSG 1991 5.9 0.37 (0.24,0.57) Robinson 1995 6.6 0.26 (0.10,0.67) Vantrappen 1988* 2.2 0.64 (0.52,0.79) Farley 2000 11.0 0.35 (0.21,0.59) Jansen 1999 5.5 0.59 (0.29,1.20) Armbrecht 1997 3.5 0.52 (0.36,0.76) Van Zyl 2000 7.6 0.09 (0.01,0.62) Soga 1999 0.6
0.50 (0.43,0.58) Overall (95% CI)
Favours PPI Favours H2RAs
Favours H2RAs
Moayyedi. Health Care Needs Assessment 2002.
Meta-analysis of PPIs vs H2RAs in oesophagitis
Meta-analysis of PPIs vs H2RAs in oesophagitis
Acid Suppression Therapy: the realities
Investigate all older patients with heartburn symptoms? How practical?
Who should be investigated?
Is empirical therapy acceptable in those without alarm symptoms?
What is pragmatic practice in Primary Care?
PPIs: empirical use
133 patients with upper GI cancer. PPI use vs no-PPI prior to investigation: 22/62 vs 1/54 normal endoscopy
747 patients with upper GI cancer.
Patients on empirical AST were referred later Time to diagnosis 44 weeks vs 17 weeks
Empirical PPI use associated with delayed diagnosis of cancer but not with staging of tumour or outcome
Bramble, Suvakovic, Hungin. Gut 1999. Panter, Bramble, O’Flanagan, Hungin. Gastroenterol (Ab) 2002.
Long Term PPIs and H pylori
Should you check the H pylori status?
>1% of UK population on long term PPIs!
Maastricht 2000: eradication recommended – potential risk of extension of atrophic changes
Malfertheiner et al., Aliment Pharmcol Ther 2002.
PPIs and interactions
Inhibition of cytochrome P450 enzyme system
Benzodiazepines, phenytoin, theophyllines, Ca channel blockers
Watch for INR control in those on warfarin!
Hungin, Rubin, O’Flanagan. Postgrad Med J 1999.
Therapy: the shorthand to the new approach…
Why investigate?
Treat symptoms – watch for alarm factors!
Likely need for long term, recurrent treatment
Do you agree with this?
Patients without alarm symptoms unlikely to have a serious problem
Empower patients to self manage?
Empowerment, Enablement, Education
Understanding the problem
Understanding the reasons for the consultation
Developing a solution that suits the patient
Why has the patient consulted?
Health and health seeking behaviour
Differences between consulters and non-consulters
Lydeard S, Jones R. Br J Gen Pract.
Health and health seeking behaviour
High vs low monitors
High vs low blunters
PPI use by patients
Established repeat prescriptions 1 year or more
<6 prescriptions per year 16%
6-9 prescriptions 27%
12 prescriptions 21%
80% of patients used PPIs intermittently!
Hungin, Rubin, O’Flanagan. Br J Gren Pract 1999.
Intermittent PPI use: reasons
“I prefer to take the treatment only when I want to”
“Only if my symptoms are a problem”
“Depends on how severe the symptoms are”
“My body might become used to the treatment”
“Fear of side effects”
“Not sure how it works…”
Symptoms and Personal Factors
Hungin, Rubin, O’Flanagan. Br J Gren Pract 1999.
Solutions to match patients’ aspirations…
Self medication where safe (nearly always!)
Prescribed therapies
OTC products
Pharmacist’s advice
SYMPTOMSSYMPTOMS
Severe, frequent, or Severe, frequent, or prolonged prolonged (regularly (regularly
exceeding 4 weeks’ exceeding 4 weeks’ duration)duration)
Physician Physician evaluatedevaluated
Symptoms Symptoms persist for persist for
periods greater periods greater than 4 weeksthan 4 weeks
Classic episodic symptoms Classic episodic symptoms of heartburn and of heartburn and
regurgitation, not exceeding 4 regurgitation, not exceeding 4 weeks’ duration and without weeks’ duration and without
alarm featuresalarm features
Recommend OTC Recommend OTC therapy with antacid, therapy with antacid,
HH22RA, or HRA, or H22RA/antacid RA/antacid
combinationcombination
SymptomsSymptomscontrolledcontrolled
PPI therapy PPI therapy treatment treatment
dosedose
Alarm or severe Alarm or severe symptoms symptoms
presentpresent
Alarm or severe Alarm or severe symptoms symptoms
absentabsent
Symptoms Symptoms persistpersist
PPI therapy trial PPI therapy trial high dose (bid)high dose (bid)
Symptoms Symptoms persistpersist
Maintain therapy with Maintain therapy with review, watching out review, watching out for signs of change in for signs of change in
symptom patternsymptom pattern
Referral to Referral to gastroenterologist for gastroenterologist for
further evaluation further evaluation and/or EGDand/or EGD
SymptomsSymptomscontrolledcontrolled
SymptomsSymptomspartially partially respondrespond
Algorithm Algorithm for the for the treatment treatment of patients of patients with heartburnwith heartburn
Dyspepsia: coping with a common problem
Nurse-led self management clinics
Pharmacist-led management
Summary
1. Common, with a low overall risk of significant lesions
2. Symptoms less pronounced in the elderly but more serious consequences
3. Investigation for the earlier detection of lesions? What role empirical therapy?
4. Management: effective acid suppression in those who warrant it; alternative therapies available!
5. Consultation behaviour: empowerment is a powerful tool!
6. New, out of the box approaches