Primary care in the treatment of functional gastrointestinal symptoms in Japan: prescription preferences and impression of results

Rome foundation Asian working team report: Real world treatment experience of Asian patients with functional bowel disorders

BACKGROUND AND AIM

Information on real world treatment experiences of patients with functional bowel disorders is lacking from Asia. This study aimed to describe the medication exposure and treatment satisfaction of patients presenting to gastroenterology clinics across a sampling of Asian cities.

METHODS

From March 2011 to October 2013, adult patients presenting to hospital-based gastroenterology outpatient clinics in 11 cities across Asia, who fulfilled screening criteria for any functional gastrointestinal disorder, were asked to complete a validated culturally adapted translation of the Rome III diagnostic questionnaire, a checklist of medications received in the preceding 3 months and questions on treatment satisfaction.

RESULTS

A total of 1376 patients (female 755, male 621, 41.36 ± 13.25 years) comprising irritable bowel (621, 45.1%), unspecified functional bowel disorder (372, 27.8%), functional constipation (202, 14.7%), functional bloating (144, 10.5%), and functional diarrhea (56, 4.1%) completed the study. Of 1105 patients with a previous consultation, 509 (46.1%) were dissatisfied with their treatment, with ineffective treatment being the commonest reason. Satisfaction with previous consultation was lowest by diagnosis for functional constipation (29.2%), and the most bothersome symptom was straining (37.5%). Of 1046 patients who had taken medications for their gastrointestinal symptoms in the last 3 months, 793 (75.8%) had received two or more drugs. For irritable bowel syndrome patients, treatment with proton pump inhibitors and antispasmodics was recorded in 57% and 31%, with overlapping epigastric pain and heartburn predicting proton pump inhibitors use.

CONCLUSIONS

More attention should be given to treatment gaps with regards to possible under-treatment with antispasmodics in irritable bowel syndrome and to critically evaluating the efficacy of constipation management.

Comparison of PPIs and H2-receptor antagonists plus prokinetics for dysmotility-like dyspepsia

AIM: To compare efficacy of proton pump inhibitors (PPIs) with H₂-receptor antagonists (H₂RAs) plus prokinetics (Proks) for dysmotility-like symptoms in functional dyspepsia (FD).

METHODS: Subjects were randomized to receive open-label treatment with either rabeprazole 10 mg od (n = 57) or famotidine 10 mg bid plus mosapride 5 mg tid (n = 57) for 4 wk. The primary efficacy endpoint was change (%) from baseline in total dysmotility-like dyspepsia symptom score. The secondary efficacy endpoint was patient satisfaction with treatment.

RESULTS: The improvement in dysmotility-like dyspepsia symptom score on day 28 was significantly greater in the rabeprazole group (22.5% ± 29.2% of baseline) than the famotidine + mosapride group (53.2% ± 58.6% of baseline, P < 0.0001). The superior benefit of rabeprazole treatment after 28 d was consistent regardless of Helicobacter pylori status. Significantly more subjects in the rabeprazole group were satisfied or very satisfied with treatment on day 28 than in the famotidine + mosapride group (87.7% vs 59.6%, P = 0.0012). Rabeprazole therapy was the only significant predictor of treatment response (P < 0.0001), defined as a total symptom score improvement ≥ 50%.

CONCLUSION: PPI monotherapy improves dysmotility-like symptoms significantly better than H₂RAs plus Proks, and should be the treatment of first choice for Japanese FD.

Large-scale randomized clinical study on functional dyspepsia treatment with mosapride or teprenone: Japan Mosapride Mega-Study (JMMS)

BACKGROUND AND AIM

Functional dyspepsia (FD) is a common condition seen in primary gastroenterology practice. The present study was conducted to compare the clinical effectiveness of mosapride and teprenone in patients with FD.

METHODS

Prospective clinical comparative study with random allocation of open labeled medications was performed as a multicenter trial in Japan. 1042 patients presenting symptoms of FD, either with gastric stasis (GSS) and/or epigastric pain (EPS), were enrolled. After initial endoscopic evaluation, medication either with mosapride 5 mg tid or teprenone 50 mg tid was started. Severity and frequency of GSS and EPS, health-related quality of life (HR-QOL) by the SF-36 Japanese version, and patients' compliance to medication was evaluated.

RESULTS

Organic lesions were found in 90 patients (9%) in the 1027 patients examined by endoscopy. Among those without any specific lesions detected by endoscopy, gastrointestinal symptoms were resolved within one week after the endoscopy in 264 (28%) patients before initiating medication. 618 patients who remained symptomatic were randomized to medication either with mosapride (n = 311) or teprenone (n = 307). Two-week treatment with mosapride significantly improved GSS and EPS, while teprenone tended to improve only GSS. Mosapride also improved HR-QOL. 91% of patients treated with mosapride favored their medication, while only 52% of patients treated with teprenone favored their medication.

CONCLUSIONS

Endoscopic evaluation at patients' presentation was effective to find active lesions and to improve FD symptoms. Mosapride was more favorably accepted than teprenone by the patients with sufficient safety and efficacy.

Diagnosis and treatment of dyspeptic patients in Japan

BACKGROUND AND AIM

Although functional gastrointestinal (GI) disorders has been paid more attention recently in Japan, similar to Western countries, the clinical characteristics of dyspeptic patients, current diagnostic approach to dyspeptic patients and current standard treatments for dyspeptic patients are not well known in Japan. This review, in the most part, summarizes two topics about Japanese dyspeptic patients. The first topic is the pros and cons of the diagnosis of Japanese dyspeptic patients using Rome III classification on the basis of our data and the second topic deals with standard treatments for dyspeptic patients-especially by primary care doctors in Japan.

METHODS

We conducted a PubMed search using the following key words alone or in combination: functional dyspepsia (FD), medical treatment, Rome III classification and Japanese.

RESULTS

The Rome III classification for FD does not adequately identify a large proportion of Japanese dyspeptic patients, primarily due to their earlier presentation for medical evaluation. There are many kinds of options for the treatment of FD in Japan: proton-pump inhibitors, histamine H(2) receptor antagonists, mucoprotective agents, Japanese traditional herbal medicines, Helicobacter pylori eradication therapy and prokinetics. Under the current situation, Japanese primary care doctors choose drugs according to each subtype of FD, which means that they prescribe medicine according to the pathogenesis of each patient.

CONCLUSIONS

While the Rome III classification seems logical, some aspects need further evaluation for Japanese dyspeptic patients. Japanese primary care doctors choose drugs appropriately based on the pathogenesis of FD. However, efforts to further elucidate underlying pathophysiologic mechanisms and identify the appropriate patient population using modified Rome classification will be required.

Comparison of the effects of omeprazole and famotidine in treatment of upper abdominal symptoms in patients with reflux esophagitis

PURPOSE

The purpose of this study was to compare the efficacy of proton pump inhibitor (PPI) with H(2) receptor antagonist (H(2)RA) in treatment of upper abdominal symptoms.

METHODS

This was a multi-center, open study conducted at 102 hospitals in Japan. Patients with reflux esophagitis received famotidine 10 mg twice daily for 2 weeks, then omeprazole 10 mg once daily for 2 weeks. Thereafter, patients were switched to famotidine 10 mg twice daily for a third 2-weekperiod, provided those with a medical condition agreed to continue the study. Patients evaluated the treatment response to each gastrointestinal symptom using a predefined patient questionnaire and gastrointestinal symptom rating scale (GSRS).

RESULTS

161 patients entered the study, of whom 8 were excluded from all analyses due to lack of participation following entry. Overall symptom improvement rate (n = 130) at week 4, after the 2-week omeprazole treatment, was 75.4% and this was significantly higher than that after the first 2-week famotidine treatment (41.5%) at week 2. In patients (n = 36) who completed 6 weeks of treatment, 2-week omeprazole treatment at week 4 showed a significantly higher overall symptom improvement rate compared with both the first 2-week and third 2-week famotidine treatments.

CONCLUSIONS

Omeprazole was superior to famotidine for treatment of upper abdominal symptoms in patients with reflux esophagitis, which suggested that gastric acid might be a cause not only of reflux symptoms, but also of ulcer symptoms and dysmotility symptoms such as epigastric pain and feeling of fullness in reflux esophagitis.