JOURNAL REVIEW

1
JOURNAL REVIEW

• Questionnaire study and audit of use of ACEI and
  monitoring in general practice
• BMJ 1999318234-237

2
Objectives

• To determine the current pattern of use of
  angiotensin converting enzyme inhibitor and
  monitoring of renal function in general practice
• To audit all admissions to a regional renal unit
  for uraemia related to use of these drugs

3
Design

• Postal questionnaire sent to 400 general
  practitioners
• Audit of clinical notes of all patients receiving
  these drugs in one large general practice
• Audit all notes of uraemia (Cr gt 500umol/L)
  related to treatment presenting to hispital renal
  services over 12 months

4
Setting

• General practices in North Wales health authority
  and one in central Manchester
• Regional renal unit in Salford

5
Outcome Measures

• Proportion of general practitioners who regularly
  monitored renal function before and after
  initiation of ACEI
• Indications for treatment and details of
  monitoring of renal function in patients
  receiving these drugs
• Incidence of related uraemia and evidence of
  co-morbid disease, other etiological factors,
  delayed detection, and patient outcome

6
Results

• 277 (69) GPs replied,
• 235 (85) checked renal function before
• But only 93 (34) after the start of treatment
• 42 (15) never checked

7
Results 2

• 162 out of total 3625 patients aged gt35 were
  prescribed ACEI
• 45 checked renal function before the start
• 29 checked after starting treatment

8
Results 3

• From the renal units
• - 9 (7) of 135 patients admitted to renal units
  for uraemia could be causally related to the use
  of ACEI
• - 3 had renovascular disease
• - 6 had congestive heart failure with another
  intercurrent illness
• - mean length of admission was 20.9 days
• - 1 died

9
Conclusion

• Cases of uraemia related to treatment with
  angiotensin converting enzyme inhibitor are still
  encountered
• These are often detected late because of lack of
  judicious monitoring of renal function in
  vulnerable, often elderly patients, especially at
  times of intercurrent illness
• Adoption of simple guidelines for monitoring of
  renal function would reduce this cause of
  morbidity and may reduce cost in long run

10
ORCHID STUDY

• Optimal Regimen Cures Helicobactor Induced
  Dyspepsia Study Group BMJ 1999318833-837

11
Introduction

• Most patients with dyspepsia do not have any
  peptic ulceration or other disease, they are
  classified as having Functional Dyspepsia
• About 50 of these patients have co-existent
  H.Pylori gastritis, but it was unclear whether
  H.Pylori causes symptoms in the absence of peptic
  ulceration.
• If so, eradication of H.Pylori should abate the
  symptoms.

12
Subjects

• Multicentre trial involving 40 centres from
  Australia, New Zealand, and nine from European
  countries.
• 244 patients were from secondary care, 31 from
  primary care
• Adult patients with dyspepsia (definition pain
  or discomfort in upper abdomen) for 3 months with
  normal OGD findings, and a positive H.Pylori
  results.
• Excluded ulcers, erosion, reflux, tumour, been
  on H2RA, prokinetics, PG in past 1 week.

13
Method

• Fill in symptom score card before, only patients
  with at least 3 days of at least moderate
  symptoms were included
• All patients underwent Urea Breath Tests to
  confirm status
• They were then randomised to either Triple
  therapy (Losec 20mg/Amoxil 1gm/Klacid 500mg bid)
  or Placebo tablet for 1 week
• Patients were considered compliant only if gt12
  doses taken

14
Follow up

• Diary cards (symptoms score and quality of life)
  were collected at 1, 3, 6, 9, 12 months after
  cessation of therapy
• No. of weak antacids consumption were recorded
• Urea breath test and OGD were performed at 3 12
  month

15
Outcome measures

• Diary cards severity of dyspeptic symptoms
  (validated Likert scale with 7 grades none,
  minimal, mild , very severe)
• Endoscopic evaluation with biopsies and
  histological gradings
• GI symptom rating score to further divide
  patients with positive dyspepsia into Ulcer-like
  or Dysmotility-like
• Successfully cured was defined as no more than
  minimal symptoms
• Chronic gastritis was considered healed when both
  biopsies specimen were free from inflammation.

16
Results

• 135 patients to treatment arm, 143 patients --
  to placebo
• Only 3 patients from all groups withdrawn because
  of unavailability of data
• The 2 groups were balanced with similar
  geographical and clinical features
• At 12 months, 85 in the treatment arm had been
  successfully cured of H.Pylori, whereas only 4
  in placebo arm

17
Results 2

• At 12 month, 81 of treatment arm had no or mild
  only gastritis, compared with 13 in placebo arm
• However, 24 only in the treatment arm were
  successfully treated, compared with 22 in the
  placebo arm at 12 month
• No significant difference in treatment success
  among those who were negative for H.Pylori (29)
  and positives for H.Pylori (21) at 12 month.

18
Results summary

• A similar proportion of patients in each
  treatment arm had no or minimal dyspepsia
  symptoms at each follow up.
• The mean symptom score were not significantly
  different at each time point.
• Mean antacid consumption over 12 months did not
  differ significantly b/w treatment (0.53) and
  placebo (0.65) groups.

19
Discussion

• Few large trials have vigorously evaluated the
  role of H.Pylori eradication in functional
  dyspepsia, and the results are conflicting.
• In this study, there was no convincing evidence
  that successful eradication of H.Pylori infection
  relieves or reduces symptoms in patients with
  functional dyspepsia over 12 months

20
Management implication

• A popular strategy in otherwise healthy young
  patients with uninvestigated dyspepsia is to test
  (non-invasively) for H. Pylori and treat all
  infected cases.
• In this study, it shows that such strategy may
  only help a minority of these patients to gain
  long-term symptomatic relief.