Dyspepsia New Approaches To Clinical Management

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DyspepsiaNew Approaches To Clinical Management

• Professor Pali Hungin
• Professor of Primary Care and General Practice
• University of Durham
• UK

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• Therapeutic Options
• Patient Empowerment

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Dyspepsia

• Who should be investigated?
• The role of H pylori test and treat?
• Therapies for dyspepsia

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Dyspepsia

• Gastro-oesophageal reflux disease 60
• Non-ulcer dyspepsia ?20
• Ulcer dyspepsia 4
• Reflux disease more accurate on clinical grounds
  but gross overlap!!

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Test and Treat

• H pylori prevalence 40, declining
• Ulcer rate 4, variable
• A worthwhile gamble?
• Non-ulcer dyspepsia benefit 115 overall

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• Manageable dyspepsia acid sensitive dyspepsia

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Prevalence of heartburn or acid regurgitation
Women at least weekly episodes Men at least
weekly episodes
40
Prevalence ()
0
2534 3544 4554 5564 6574 Age (years)
Locke et al., Gastroenterology 1997112144856.
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Prevalence of GERD by age and sex
900
Males
800
Females
700
600
Prevalence per 10,000 population
500
400
300
200
100
12-24
24-44
45-64
64-74
Age group
El-Serag Sonnenberg, Gut 199741594-9.
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Heartburn as a risk factor for oesophageal
adenocarcinoma
Frequency and duration of symptoms
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Frequency Chronicity
16.7
16.4
Odds ratio
7.5
6.3
5.2
5.1
1
1
0
None 1 23 gt3 0 lt12 1220 gt20
Heartburn episodes/week Duration of symptoms
(years)
Lagergren et al., N Engl J Med 199934082531.
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Mortality due to oesophageal adenocarcinoma in
England and Wales
4000
3500
3000
2500
Mortality
2000
1500
1000
500
0
79
89
94
84
97
Year
Office of National Statistics, 1999.
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Range of presentations of GERD
Typical symptoms (Heartburn/regurgitation)
Atypical symptoms
Complications
With oesophagitis
Chest pain(visceral hyperalgesia)
Oesophageal erosions and/or ulcers
Without oesophagitis
Stricture
Hoarseness (reflux laryngitis)
Barretts oesophagus
Asthma, chronic cough, wheezing
Oesophageal adenocarcinoma
Dental erosions
Nathoo, Int J Clin Pract 2001554659.
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If I had known I was going to live this long I
would have taken better care of myself!George
Burns at age 95
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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

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Consequences of severe and prolonged GERD
Savary-Miller Grade IV and above

• Oesophageal stricture
• Barretts oesophagus
• Oesophageal adenocarcinoma
• Anaemia

Nathoo, Int J Clin Pract 2001554659.
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GERD presentation in the older patient

• Common
• Often less severe and less frequent symptoms
• Dysphagia, vomiting and anaemia more common

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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.
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ManagementBasic principles

• Effective symptom relief
• Earlier detection of serious lesions
• Prevention of complications

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The earlier detection of lesions

• Early investigation
• New presentations
• Alteration in symptoms or response to therapy
• Alarm symptoms

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Treatment options
Lifestyle modifications
Antacids and alginates
PPIs
H2RAs
Approaches
Prokinetic motility agents
Surgery
Hatlebakk Berstad, Clin Pharmacokinet
199631386406.
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Alginates

• Superior to antacids
• Are not antacids!
• Do not interact adversely with PPIs
• Fast relief
• Can be used for topping up

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Acid suppression therapy

• Empirical therapy or only post-investigation?
• H2-receptor blockers
• PPIs
• Old patients may require greater acid suppression
  to heal oesophagitis

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H2-receptor antagonists (H2RAs)

• 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 20013237369. Sonnenberg,
Pharmacoeconomics 200017391401.
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Meta-analysis of PPIs vs H2RAs in oesophagitis
Study
Risk ratio (95 CI)
Weight
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
Overall (95 CI)
0.50 (0.43,0.58)
Favours H2RAs
.012003
1
83.3135
Risk ratio
Favours PPI Favours H2RAs
Moayyedi. Health Care Needs Assessment 2002.
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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?

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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, OFlanagan, Hungin. Gastroenterol (Ab)
2002.
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Long Term PPIs and H pylori

• Should you check the H pylori status?
• gt1 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.
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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, OFlanagan. Postgrad Med J 1999.
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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?

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Empowerment, Enablement, Education

• Understanding the problem
• Understanding the reasons for the consultation
• Developing a solution that suits the patient

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Why has the patient consulted?

• Health and health seeking behaviour
• Differences between consulters and non-consulters

Lydeard S, Jones R. Br J Gen Pract.
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Health and health seeking behaviour

• High vs low monitors
• High vs low blunters

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PPI use by patients

• Established repeat prescriptions 1 year or more
• lt6 prescriptions per year 16
• 6-9 prescriptions 27
• 12 prescriptions 21
• 80 of patients used PPIs intermittently!

Hungin, Rubin, OFlanagan. Br J Gren Pract 1999.
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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, OFlanagan. Br J Gren Pract 1999.
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Solutions to match patients aspirations

• Self medication where safe (nearly always!)
• Prescribed therapies
• OTC products
• Pharmacists advice

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Dyspepsia coping with a common problem

• Nurse-led self management clinics
• Pharmacist-led management

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Summary

• Common, with a low overall risk of significant
  lesions
• Symptoms less pronounced in the elderly but more
  serious consequences
• Investigation for the earlier detection of
  lesions? What role empirical therapy?
• Management effective acid suppression in those
  who warrant it alternative therapies available!
• Consultation behaviour empowerment is a powerful
  tool!
• New, out of the box approaches