HOT TOPIC: DYSPEPSIA AND H'PYLORI HP TESTING

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HOT TOPIC DYSPEPSIA AND H.PYLORI (HP) TESTING

• Sarah Love
• GP Registrar

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What guidelines do we use in practice?

• NICE 2004 Dyspepsia management in primary care.
• SIGN 2003 Dyspepsia.
• Local Tayside protocol

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DYSPEPSIA MANAGEMENT IN PRIMARY CARENICE
Guideline 2004, Update June 2005

• Review medications for possible causes of
  dyspepsia (calcium antagonists,nitrates,
  theophyllines, bisphosphonates, corticosteroids
  and NSAIDs).
• Suspend NSAID use.

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• Urgent specialist referral for endoscopy is
  indicated for patients of any age with dyspepsia
  when presenting with any of the following
• chronic GI bleeding
• progressive unintentional weight loss
• progressive difficulty swallowing
• persistent vomiting
• iron deficiency anaemia
• epigastric mass
• suspicious barium meal
• Routine endoscopic investigation of patients of
  any age presenting with dyspepsia and without
  alarm signs is not necessary.
• However, in patients aged 55 years and older with
  unexplained and persistent recent onset dyspepsia
  alone, an urgent referral for endoscopy should be
  made.

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Interventions for uninvestigated dyspepsia

• Empirical treatment with a PPI or testing for and
  treating HP.
• There is currently insufficient evidence to guide
  which should be offered first.
• A 2-week washout period following PPI use is
  necessary before testing for HP with a breath
  test or a stool antigen test.

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Interventions for endoscopically determined
non-ulcer dyspepsia

• Treatment for H. pylori if present, followed by
  symptomatic management and periodic monitoring.
• Re-testing after eradication should not be
  offered routinely, although the information it
  provides may be valued by individual patients.

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Reviewing patient care

• Annual review of their condition.
• Encourage them to try stepping down or stopping
  treatment.
• A return to self-treatment with antacid and/or
  alginate therapy may be appropriate.

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H. pylori testing and eradication

• HP can be initially detected using either
• -carbon-13 urea breath test
• -stool antigen test
• -laboratory-based serology (where locally
  validated)
• Office-based serological tests for HP cannot be
  recommended because of their inadequate
  performance.
• For patients who test positive provide a 7-day
  course of treatment.
• Full-dose PPI with either metronidazole 400 mg
  and clarithromycin 250 mg or amoxicillin 1 g and
  clarithromycin 500 mg.

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Tayside algorithm (based on SIGN guidelines)
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Original evidence

• NICE/SIGN guidelines based on evidence from Manes
  et al. BMJ 2003 which evaluated the test and
  treat strategy for HP using breath tests.
• Found it was as safe as endoscopy in a low risk
  population without alarm symptoms or signs.
• Assoc. with a decrease in long-term symptoms
  compared to acid suppression alone.

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Newer evidence for test and treat strategy

• Lassen et al. Gut 2004
• Large study looking at patients presenting with
  dyspepsia in primary care.
• Groups were test and treat v endoscopy.
• 7 year follow up showed no difference in symptoms
  or wellbeing.
• Endoscopied group used more drugs.

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Different tests available

• Discussed in editorial in BMJ 2005.
• Serology testing can be inaccurate and stays
  positive despite eradication.
• Most accurate tests are
• Breath tests expensive and requires referral.
• Stool antigen test- uses antibody to detect
  antigen in stool. Less expensive and can be used
  to indicate eradication BUT involves poo!
• Need to stop antibiotics 4 weeks before and PPIs
  2 weeks before these tests.

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Groups who benefit from HP eradication

• BMJ editorial Delaney et al. Jan 2006
• - Proven peptic ulcer NNT 2.
• - Functional and non-investigated
  dyspepsia NNT 15.
• Lane et al. BMJ Jan 2006
• - Screened 10,000 people age 20-59 for HP.
• 15 of were HP ve.
• Randomised to eradication or no eradication.
• 2 year follow up- eradication group had
  significantly less consultations and dyspeptic
  symptoms.
• NNT 30