Survey of dyspepsia management in community

INTRODUCTION

Dyspepsia is a common complaint and represents an important health problem in the community. The aim of the study was to survey the diagnostic approach and management of dyspepsia and Helicobacter pylori (H. pylori) infection by primary care physicians.

METHODS

Questionnaires were given to 70 medical officers (MO) working in government polyclinics and 70 general practitioners (GP) in private practice.

RESULTS

Questionnaires were returned from 68 MO's (response rate 97%) and 61 GP's (response rate 87%). Only 20% of MO and 50% of GP prescribed H. pylori eradication therapy. Of those who have prescribed eradication therapy, 70% would confirm H. pylori infection before therapy (50% for gastroscopy, 19% for Urea Breath test, 25% for laboratory based serology, 6% for office based serology test kits). 85% would prescribe triple therapy against 15% for dual therapy. Proton pump inhibitor (PPI) is the acid suppression agent most commonly prescribed (77%) in regimens of eradication therapy; the remaining would prescribe either bismuth subcitrate or H2 antagonists. Only 8% of respondents would confirm eradication after therapy.

CONCLUSION

Less than half of the primary care physicians surveyed prescribed H. pylori eradication therapy. The main reason given for not prescribing therapy was lack of facility for testing the infection. Of those who prescribed eradication therapy, majority would order the correct and reliable investigations to confirm the infection. Most of them would prescribe triple therapy which is the recommended eradication regimens.

"Cervia Working Group Report": guidelines on the diagnosis and treatment of Helicobacter pylori infection

Different national attitudes exist between countries in Europe concerning eradication of Helicobacter pylori infection due to the wide differences in Helicobacter pylori prevalence, gastric cancer risk, bacterial resistance to antibiotics, health care systems and financial resources. The Cervia Working Group Report has been established in order to fill the gap in the absence of National Guidelines in Italy concerning the diagnosis and treatment of Helicobacter pylori infection. The recommendations made are, by and large, similar to the European Guidelines but differ slightly with regard to the "test-and-treat" approach to young dyspeptics without sinister symptoms. In the absence of a national validation of this strategy a case-by-case assessment of dyspepsia has been promoted, both at primary care and specialist level. Another area of partial disagreement concerns the eradication of Helicobacter pylori in patients undergoing long-term proton pump inhibitor treatment which has not been generally recommended as scientific evidence in support of this policy is at present rather weak.

Pharmacology and clinical experience with fedotozine

Fedotozine [(1R)-1-phenyl-1-[(3,4,5-trimethoxy)benzyloxymethyl]-N,N- dimethyl-n-propylamine, (2S,3S-tartrate] is derived from the arylacetamide series. As with other compounds of this series, fedotozine is more or less selective of kappa(1)-opioid receptors and particularly for the kappa(1a)-receptor subtype, where it acts as an agonist. Pharmacological studies have shown that fedotozine exerts a peripheral antinociceptive action, comparable with that of other kappa-agonists. Its main effects have been demonstrated at the level of the afferent nerve pathways originating from the gut. Fedotozine alters the processing of visceral sensations along these pathways and hence, the perception of gut stimuli at the brain level. It modifies reflexes induced in various pathological conditions, like experimental inflammation of the gut, chemically-induced peritonitis or post-operative ileus. Fedotozine also decreases the nociceptive reflexes triggered by noxious gut distension in animals. In humans, fedotozine decreases the perception of gut distension, both in physiological and pathological conditions. Clinical trials undertaken in patients with functional digestive disorders, non-ulcer dyspepsia and irritable bowel syndrome, have shown that fedotozine relieves abdominal pain in these patients in 6-week treatments. kappa-Opioid receptors remain an interesting area for future development of new treatments for abdominal pain in patients with functional digestive disorders.

Eradication of Helicobacter pylori has no effect on gastric acidity in duodenal ulcer patients--evaluation of 24-h pH monitoring

It is accepted that eradication of Helicobacter pylori leads to healing of chronic active gastritis facilitates ulcer healing and prevents ulcer recurrence in duodenal ulcer (DU) patients. However, it is not entirely known whether the eradication of the bacteria normalizes gastric acid secretion and abolishes dyspeptic symptoms after ulcer healing. This study was aimed to evaluate the intragastric acidity and dyspeptic complaints before, and 3 months after, eradication in 18 endoscopically proven H. pylori positive DU patients. Gastric pH was measured by 24-h continuous intraluminal recording, serum gastrin measurements and Congo-red tests were also performed. Dyspeptic complaints and antacid consumptions were recorded in diary cards, antisecretory therapy was not allowed after the cessation of eradication therapy. Endoscopy, H. pylori status and Congo-red tests were controlled at the 6th and 12th week, while pH measurements and serum gastrin tests were performed at inclusion and 3 months later. Three patients dropped out and in 14 out of the remaining subjects healing of DUs and successful eradication was achieved by the 6th and 12th week controls. The 24-h median pH and the percentage of 24-h pH readings under pH 3 were not changing significantly by the 3-month controls (from 1.9+/-0.5 to 1.8+/-0.4 and from 52.6+/-5.5% to 58.6+/-5%, respectively). Similarly, no significant changes were observed in serum gastrin levels and dyspeptic symptom scores (from 72+/-7 pg/ml to 56.7+/-8 pg/ml and from 2.69+/-0.4 to 1.26+/-0.3, respectively). The antacid consumption was almost stable when compared with the pre- and post-eradication periods. It was concluded that despite successful H. pylori eradication and healing of DU, intragastric acidity does not change significantly at least 3 months after the therapy. The persisting dyspeptic symptoms and the need for antacid consumption suggest that some healed ulcer patients require antisecretory therapy in the post-eradication period.

Efficacy and tolerability of a fixed combination of peppermint oil and caraway oil in patients suffering from functional dyspepsia

AIM

To assess the efficacy and safety of enteric coated capsules containing a fixed combination of 90 mg peppermint oil and 50 mg caraway oil (PCC; Enteroplant) in patients with functional dyspepsia.

METHODS

A total of 96 out-patients received one capsule twice daily of PCC or placebo for 28 days. Primary efficacy variables were the intra-individual change in (i) pain intensity and (ii) sensation of pressure, heaviness and fullness between days 1 and 29, and the investigators' rating of (iii) global improvement (Clinical Global Impressions [CGI] item 2) on day 29. A global type I error of alpha=0.05 was controlled by a priori ordering of hypotheses.

RESULTS

All patients were evaluable for efficacy and safety. On day 29, the average intensity of pain was reduced by 40% vs. baseline in the PCC group and by 22% in the placebo group. With regards to pressure, heaviness and fullness, a 43% reduction was observed for PCC vs. 22% for placebo. In CGI item 2, 67% (PCC) vs. 21% (placebo) of the patients were described as much or very much improved. In all three target parameters, the superiority of PCC over placebo was statistically significant. Six patients (PCC: 5; placebo: 1) reported adverse events, either unrelated to the trial, or attributable to an aggravation of the disease under investigation. Eructation with peppermint taste did not occur.

CONCLUSION

These results demonstrate the good tolerability and the favourable risk-benefit ratio of PCC for the treatment of functional dyspepsia.

Failure of a motilin receptor agonist (ABT-229) to relieve the symptoms of functional dyspepsia in patients with and without delayed gastric emptying: a randomized double-blind placebo-controlled trial

INTRODUCTION

Motilin-receptor agonists are prokinetics; whether they relieve the symptoms of functional dyspepsia is unknown. We aimed to test the efficacy of the motilin agonist ABT-229 in functional dyspepsia patients with and without delayed gastric emptying.

METHODS

Patients were randomized with postprandial symptoms and documented functional dyspepsia by endoscopy (n=589 in intention-to-treat analysis). Patients were assigned to either the delayed or normal gastric emptying strata, based on a validated 13C octanoic acid breath test. Patients were then further randomized within each strata, to receive one of four doses of ABT-229 (1.25, 2. 5, 5 or 10 mg b.d. before breakfast and dinner) or placebo for 4 weeks, following a 2-week baseline. The primary outcome was the assessment of change in symptom severity over the 2 weeks from baseline to final visit, based on a self-report questionnaire measuring severity on visual analogue scales.

RESULTS

Baseline characteristics across the treatment arms were very similar. No significant differences in the upper abdominal discomfort severity score (maximum 800 mm) were observed for any active treatment arm vs. placebo (mean change from baseline -139, -141, -145, -160 and -134 mm for placebo, 1.25, 2.5, 5, and 10 mg, respectively, at 4 weeks by intention-to-treat). More patients on placebo reported a good or excellent global response than patients on 1.25 or 5 mg of active therapy (both P < 0.05). The results were very similar in those with and without delayed gastric emptying. Helicobacter pylori status did not predict response. Excluding patients with any baseline heartburn (total remaining n=240), ABT-229 10 mg was inferior to placebo in relief of upper abdominal discomfort.

CONCLUSIONS

ABT-229 was of no value for relief of symptoms in functional dyspepsia, compared with placebo.

Investigation and therapy in patients with different types of dyspepsia: a 3 year follow-up study from general practice

BACKGROUND

Decisions by GPs on investigation and treatment are based on the symptoms presented by the patient. The relevance of dyspepsia subgroups has been questioned, but their value in general practice has not been tested.

OBJECTIVE

The aim of this study was to investigate how dividing dyspepsia into different subgroups (ulcer-like, reflux-like, dysmotility-like, uncharacteristic and relapsing dyspepsia) affected the approach of GPs to patients with dyspeptic complaints.

METHODS

A random sample of GPs' patients consulting for different dyspepsia subtypes were studied by postal questionnaires 3 years after the initial consultation, obtaining information from the GPs' records on investigations, prescriptions of dyspepsia medication and gastrointestinal morbidity.

RESULTS

In the 3 years studied, 48% of the patients were prescribed dyspepsia medication, 14% were endoscoped and 3% were referred to a specialist. The dyspepsia subtype was significantly related to the type of drug prescribed, but not to investigations or referrals. Ulcer-like and reflux-like dyspepsia were treated in the same way.

DISCUSSION

Dyspepsia subtypes significantly influenced the treatment. Danish GPs treat all acid-related dyspepsia in the same way, and differently from other types of dyspepsia.

Relief of dyspeptic symptoms by colloidal bismuth subcitrate in Helicobacter-negative and -positive patients: results of a study in general practice

BACKGROUND

The role of H. pylori in non-ulcer dyspepsia is controversial. Colloidal bismuth subcitrate (CBS) is known to suppress H. pylori. We hypothesized that if H. pylori is a causal factor in dyspepsia, then suppression of H. pylori would lead to a decrease in symptoms.

AIM

To assess the relationship between H. pylori status and the effect of CBS on dyspeptic symptoms in patients visiting their general practitioner for dyspeptic complaints.

METHODS

In total 446 patients between 17 and 81 years of age (median 44 years) were included. All patients were treated with CBS (240 mg Bi2O3) twice a day for 4 weeks. Symptoms were scored at baseline, and after 2 and 4 weeks of treatment. At the first visit, blood was taken for serological H. pylori testing.

RESULTS

During follow up, 65 patients were lost due to violation of protocol. Positive H. pylori serology was found in 110 (24.7%) of the 446 initially selected patients, and in 90 (23.6%) of the 381 patients who completed the protocol (NS). The mean overall symptom score decreased significantly after 4 weeks of CBS (P<0.001). This reduction in overall symptom score was not significantly different between the H. pylori-positive and -negative groups.

CONCLUSIONS

The H. pylori status does not influence the outcome of CBS therapy in patients who consult their general practitioner for dyspepsia. This finding suggests that H. pylori does not play an important role in the etiology of dyspepsia in patients seen by the general practitioner.

How the reimbursement system may influence physicians' decisions results from focus groups interviews in France

This paper analyzes how physicians' treatment choices are influenced by cost to the patient for four different diseases in France: mild hypertension, hay fever, dyspepsia and hormone replacement therapy (HRT). Five focus groups of physicians were conducted in the fall of 1998. The paper reviews the type of shifts and strategies physicians used to reduce the cost to the patient. In order to maintain access to care for the patients, the most common strategy used is to refer to different types of social structures in the health care system. However, a number of shifts related to drug or treatment choices were also identified such as prescription of older drugs, shifts to drugs having different drug coverage and cheaper drugs within a drug class. In a proportional system of copayment, the price level of the services (drugs or exams) clearly appeared as a determining factor to induce physicians' decision shifts. Overall, we also found that French physicians put higher priorities on the cost to society than on the cost to the patient in their treatment decisions.

Drug-induced symptoms of functional dyspepsia and nausea. A symmetry analysis of one million prescriptions

BACKGROUND

A large variety of drugs have been implicated in causing dyspepsia. Due to the high background incidence of dyspepsia it is impossible to distinguish between spontaneous and truly drug-related symptoms. Most patients with dyspeptic symptoms are treated empirically. Drug-induced dyspepsia might therefore be reflected in the sequencing of prokinetics relative to other medications.

AIM

To screen a large prescription database for signs of drug-induced functional dyspepsia, applying a symmetry principle.

METHODS

Prescription data on all incident users of cisapride and metoclopramide were used to identify individuals who had started their first therapies with a prokinetic drug and an index drug within a 100-day span. A dyspepsia-provoking effect of the index drug would manifest as an excess of persons with the prokinetic drug prescribed last in this selected population. Relative to conventional analyses based on case-control or cohort design, this principle is robust to confounders that are stable over time.

RESULTS

In the cisapride analysis (1825 persons) no single drug had adjusted rate ratios significantly above unity. An inverse signal for antidepressants (rate ratio 0.57; 95% CI: 0.39-0.84) suggests that these drugs may have a therapeutic effect against functional dyspepsia. In the metoclopramide analysis (6126 persons) positive signals were found for 14 drugs, all well-known for causing nausea as a side-effect, with the exception of insulin (rate ratio 2.91, 95% CI: 1.40-8.11).

CONCLUSIONS

Drug-induced symptoms of functional dyspepsia are rare and do not contribute to the use of cisapride. The start of insulin treatment may induce nausea.

Relationship between antral lymphocyte density and basal gastrin levels in patients with Helicobacter pylori infection

BACKGROUND

The mechanism by which Helicobacter pylori causes hypergastrinaemia is not completely understood.

AIM

To evaluate whether antral lymphocyte density could play a role in this alteration.

METHODS

A total of 12 patients with active duodenal ulcer and 10 with non-ulcer dyspepsia were enrolled upon detection of Helicobacter pylori infection at endoscopy Enrolled as controls were 7 matched dyspeptic patients without Helicobacter pylori infection. Biopsy specimens were collected for Helicobacter pylori and histological assessments, and for antral lymphocyte density assessment by a histomorphometric method. A blood sample was obtained from each patient to determine basal gastrin levels. All patients were controlled by a further endoscopy 4 weeks after the end of Helicobacter pylori treatment.

RESULTS

Antral lymphocyte density (5,464 +/- 1,328 and 5,635 +/- 1,186 vs 2,267 +/- 557 lymphocytes/mm2; p<0.001 and p<0.001, respectively) and gastrin levels (66.7 +/- 14.1 and 60.4 +/- 21.7 vs 40.7 +/- 7.8 pg/dl; p=0.004 and p=0.02, respectively) were higher in duodenal ulcer and non-ulcer dyspepsia patients than in controls, while no significant differences emerged between duodenal ulcer and non-ulcer dyspepsia patients. There was a significant direct correlation between antral lymphocyte density and gastrin levels both in duodenal ulcer (r=0.77; p=0.003) and in non-ulcer dyspepsia (r=0.75; p=0.03) patients, while no correlation was found in controls [r=0.12; p=0.8). After treatment, this correlation persisted in 10 eradication failure patients (r=0.68; p=0.027), but disappeared in those successfully cured.

CONCLUSIONS

These data suggest that lymphocyte density in the antral mucosa could play a role in the impaired gastrin production occurring in patients with Helicobacter pylori infection.

Identifying responders to acid suppression in dyspepsia using a random starting day trial

BACKGROUND

Functional dyspepsia is a heterogeneous condition and a uniform response to drug treatment is not likely. This may be the reason for the general failure of acid suppression in clinical trials in these patients. It may be more rewarding to identify true responders to drug treatment by a single subject trial.

AIM

To develop and to test a novel single subject trial design (random starting day trial) in dyspeptic patients.

PATIENTS AND METHODS

A total of 301 dyspeptic patients entered a 16-day trial. All patients received placebo for the first 4 days and switched to omeprazole at a randomized and blinded day between day 5 and day 14. Response was defined as a sustained >/= 50% decrease in symptom score occurring in relation to drug shifting.

RESULTS

Spontaneous response varied between 0.3% and 10.6% per day, uniformly distributed over time. Overall, 53-61% of patients with organic dyspepsia had a symptom response in relation to shifting to active treatment, compared to only 23% of patients with functional dyspepsia. The only predictor of response was symptoms suggesting gastro-oesophageal reflux.

CONCLUSIONS

A random starting day trial may be a valuable tool to identify response to acid suppression in dyspeptic patients.

Which dyspepsia patients will benefit from omeprazole treatment? Analysis of a Danish multicenter trial

OBJECTIVE

The effect of omeprazole therapy in dyspepsia is unpredictable. The aim of this study was to identify patient characteristics and symptoms associated with the omeprazole response to improve selection of patients for empirical treatment with omeprazole.

METHODS

Data from a randomized controlled trial of 471 patients with ulcer-like or reflux-like dyspepsia treated with omeprazole 20 mg daily (243 patients) or placebo (228 patients) for 2 wk were studied using logistic regression analysis. The patients were randomly divided into a model sample (N = 236) for modeling the association between the omeprazole response and descriptive variables, and a test sample (N = 235) for testing the obtained model.

RESULTS

In the model sample a high body mass index, the use of antacids or H2-blockers within the last month, or pain at night time were independently associated with a good omeprazole response, whereas the presence of nausea was associated with a poor omeprazole response. Using these variables combined into a therapeutic index, the independent test sample patients could be classified into predicted good (N = 56), medium (N = 88), and poor omeprazole responders (N = 91). In these groups the observed therapeutic gain of omeprazole (omeprazole response minus placebo response) was 39.4%, 19.3%, and 4.6%, respectively (p = 0.013). For clinical use, an easy-to-use pocket chart to obtain the therapeutic index in a given patient has been devised.

CONCLUSIONS

In dyspepsia the identification of potential responders to omeprazole can be improved by considering certain patient characteristics and symptoms associated with the omeprazole response. Applying these data using a simple pocket chart may assist decision about empirical omeprazole therapy in patients with dyspepsia in general practice.

Short course acid suppressive treatment for patients with functional dyspepsia: results depend on Helicobacter pylori status. The Frosch Study Group

BACKGROUND AND AIMS

Treatment of functional dyspepsia with acid inhibitors is controversial and it is not known if the presence of Helicobacter pylori infection influences the response.

METHODS

After a complete diagnostic workup, 792 patients with functional dyspepsia unresponsive to one week of low dose antacid treatment were randomised to two weeks of treatment with placebo, ranitidine 150 mg, omeprazole 10 mg, or omeprazole 20 mg daily. Individual dyspeptic and other abdominal symptoms were evaluated before and after treatment according to H pylori status.

RESULTS

The proportions of patients considered to be in remission (intention to treat) at the end of treatment with placebo, ranitidine 150 mg, omeprazole 10 mg, and omeprazole 20 mg were, respectively, 42%, 50%, 48%, and 59% in the H pylori positive group and 66%, 73%, 64%, and 71% in the H pylori negative group. In H pylori positive patients, the therapeutic gain over placebo was significant for omeprazole 20 mg (17.6%, 95% confidence intervals (CI) 4.2-31.0; p<0.014 using the Bonferroni-adjusted p level of 0.017) but not for omeprazole 10 mg (6.8%, 95% CI -6.7-20.4) or ranitidine 150 mg (8.9%, 95% CI -4.2-21. 9). There was no significant therapeutic gain from active treatment over placebo in H pylori negative patients. Complete disappearance of symptoms and improvement in quality of life also occurred most frequently with omeprazole 20 mg and was significant in both H pylori positive and H pylori negative groups. The six month relapse rate of symptoms requiring treatment was low (<20%) in all groups.

CONCLUSIONS

Omeprazole 20 mg per day had a small but significant favourable effect on outcome in H pylori positive patients. The differential response in these patients may be explained by an enhanced antisecretory response in the presence of H pylori. The effect of weaker acid inhibition was unsatisfactory.

[IgG and IgA immunoglobulins in helicobacter pylori infections of children with chronic dyspepsia before and after two week triple drug therapy]

The aim of this study was to investigate whether serological techniques, ELISA and Western blot, are useful in monitoring treatment of H. pylori-associated chronic dyspeptic symptoms in children. We observed a correlation between a decrease in the anti-H. pylori IgG titer and an effective treatment. So, our results suggested that the ELISA assay conducted with a glycine H. pylori extract can be a good noninvasive assay for monitoring the effectiveness of the therapy. By using the Western blot method, we showed some variation in the specificity of anti-H. pylori IgG produced before and after treatment. However, this variation was not correlated with the effectiveness of the therapy.