Proton pump inhibitors may mask early gastric cancer. Dyspeptic patients over 45 should undergo endoscopy before these drugs are started

PPIs and gastric cancer: any causal relationship?

Hydrochloric acid is crucial in gastric physiology. In 1978 cimetidine, the first H2 antagonist of histamine receptors on the gastric parietal cell was introduced into therapy, inducing acid. Lasting the years, several studies focused on the potential relationship between inducing hypo-achlorhydria and risk of developing gastric cancer. In 1988 omeprazole, the first proton pump inhibitor, entered therapy. In 1996, Kuipers underlined the danger of progression of chronic atrophic gastritis in subjects taking PPIs. In 2018, one paper from Korea and an another on from Sweden suggested a possible relationship between long-term PPI therapy and the development of gastric cancer. Over the years, several articles, meta-analyzes and population based  focused on relationship between long-term of PPI use and the onset of gastric cancer, with conflicting results. As reported, the presence of bias in the collection of cases, in particular concerning the evaluation of the H.p. status and presence of atrophic gastritis and intestinal metaplasia in subjects treated with PPI, can lead to noticeable errors in the results and conclusions, as demonstrated in the literature by exhaustive methodological studies of pharmacoepidemiology. A possible bias in the collection of case histories is due to the fact that PPIs are often administered to dyspeptic patients, among which there are patients already carriers of gastric neoplasia: the so-called inverse causality.  Literature data, amended by methodological bias (sampling errors, lack of comparative assessment of Hp status and atrophic gastritis) NOT support a causal relationship between long-term PPIs therapy and the onset of gastric cancer.

Use of proton pump inhibitors and histamine-2 receptor antagonists and risk of gastric cancer in two population-based studies

BACKGROUND

Studies have shown increased gastric cancer risk in users of proton pump inhibitors (PPI) and histamine-2 receptor antagonists, questioning the safety of gastric acid suppression. Therefore, we conducted a case-control study within the Scottish Primary Care Clinical Informatics Unit (PCCIU) database and a cohort study in the UK Biobank.

METHODS

In PCCIU, five controls were matched to cases diagnosed in 1999-2011, and medications were determined from GP records. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using conditional logistic regression. In the UK Biobank, medications were self-reported at cohort entry 2006-2010, and gastric cancer ascertained from cancer registries until 2014. Hazard ratios (HR) were calculated using Cox regression.

RESULTS

PCCIU contained 1119 cases and 5394 controls. UK Biobank contained 250 cases in 471,779 participants. PPI users had a higher gastric cancer risk in PCCIU and UK Biobank when applying a 1-year lag (adjusted OR = 1.49, 95% CI 1.24, 1.80; adjusted HR = 1.28, 95% CI 0.86, 1.90, respectively), but these associations were attenuated when using a 2-year lag (adjusted OR = 1.13, 95% CI 0.91, 1.40; adjusted HR = 1.15, 95% CI 0.73, 1.82, respectively).

CONCLUSIONS

Overall, we observed little consistent evidence of an increased risk of gastric cancer with PPI use.

We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Effects of administration of a proton pump inhibitor before endoscopic submucosal dissection for differentiated early gastric cancer with ulcer

BACKGROUND

In ulcerative early gastric cancer, improvement and exacerbation of ulceration repeat as a malignant cycle. Moreover, early gastric cancer combined with ulcer is associated with a low curative resection rate and high risk of adverse events. The aim of this study was to investigate the ulcer healing rate and clinical outcomes with the administration of a proton pump inhibitor before endoscopic submucosal dissection for differentiated early gastric cancer with ulcer.

METHODS

A total of 136 patients with differentiated early gastric cancer with ulcer who met the expanded indications for endoscopic submucosal dissection were reviewed between June 2005 and June 2014. Eighty-one patients were given PPI before endoscopic submucosal dissection and 55 patients were not given PPI.

RESULTS

The complete ulcer healing rate was significantly different between the two groups (59.3 % vs. 23.6 %, P < 0.001). The procedure time was 38.1 ± 35.7 and 50.8 ± 50.2 min (P = 0.047). However, no significant differences were detected in the en bloc resection rate, complete resection rate, and adverse events including bleeding and perforation. Multivariate analysis showed that administration of PPI (OR = 10.83, P < 0.001) and mucosal invasion (OR = 24.43, P < 0.001) were independent factors that predicted complete healing of ulceration. The calculated accuracy for whether complete healing of the ulcer after PPI administration can differentiate mucosal from submucosal invasion was 75.3 %.

CONCLUSIONS

Administration of PPI before ESD in differentiated EGC meeting the expanded criteria is effective to heal the ulcer lesion and reduce the mean procedure time. Complete healing of the ulcer after PPI administration suggests mucosal cancer.

Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study

Objectives

To evaluate the appropriateness of proton pump inhibitor (PPI) prescribing by conducting an audit of medical inpatients against recommended guidelines.

Design

Questionnaire-based study. All medical wards were audited and different information was documented by patients' medical records review (both hospital visit notes and general practitioner's letters) and short interview, where we asked them to name the clinical reason for using PPI.

Setting

This study was carried out in the setting of a regional hospital (537-bed, secondary care referral centre) in Ireland.

Participants

The study participants were all consecutive medical patients admitted to the medical wards at Waterford Regional Hospital, Waterford.

Main outcome measures

The appropriateness of PPI usage in our regional hospital by assessing the level of its prescribing against published guidelines (NICE, 2000).

Results

During the audit period, 205 consecutive medical inpatients were assessed. Seventy-nine percent (162 out of 205) of the studied patients were found to be using PPI. For 45% (n = 73) of patients, there was no documentation of valid indication for being on PPI. Overall, 64% of patients were prescribed PPI by hospital doctors, either during their current or previous admissions. We noted that 31% (n = 51) of patients were taking PPI for ≥2 years and another 25% of patients were using PPI for about one year. Only 12% (n = 20) of patients had undergone endoscopy procedures.

Conclusion

Inappropriate use of PPI remains common in hospital practice. The risks of using long-term PPI must be weighed against the benefits.

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

Time-dependent morphologic change in depressed-type early gastric cancer

BACKGROUND

Depressed-type early gastric cancer (EGC) is known to repeat improvement and exacerbation of ulceration during its natural course, forming a "malignant cycle." However, it is difficult to observe the malignant cycle of EGC in clinical practice, and little is known about the clinicopathologic factors associated with this cycle. This study aimed to evaluate the malignant cycle of EGC and to determine the clinicopathologic factors associated with the time-dependent morphologic change of EGC.

METHODS

The medical records of EGC patients treated at the Seoul National University Hospital were retrospectively reviewed with two or more comparable endoscopic photos taken between March 1999 and December 2005. The ulcer stages in EGC were classified by the gastric ulcer stage system and evaluated for time-dependent morphologic changes according to the relevant factors.

RESULTS

In this study, 231 cases of depressed-type EGC were evaluated. At the follow-up endoscopy after a median interval of 23 days, a change in ulcer stage was observed in 66 patients (29%), with improvement in 45 patients (20%) and exacerbation in 21 patients (9%). Of the 177 patients who demonstrated an active or healing stage, 45 (25%) showed improvement and 10 (6%) exhibited exacerbation. The multivariate analysis showed that the usage of antisecretory medications, mucosal cancer, and a longer interval between the two endoscopic examinations were the factors that had a significant association with improvement of the ulcer stage.

CONCLUSIONS

The malignant cycle was frequently observed in depressed-type EGC. The improvement of ulceration in EGC was time dependent and associated with the usage of antisecretory medication and the depth of invasion.

Prognostic significance of gastrin expression in patients undergoing R0 gastrectomy for adenocarcinoma

BACKGROUND

Gastrointestinal (GI) hormones regulate several GI functions, including the proliferation and repair of normal mucosa, and hormone receptors may therefore be implicated in the growth, invasion, and metastasis of cancers of the GI tract. The aim of this study was to determine the cellular distribution of gastrin in intestinal-type gastric cancers, and to determine its relationship to outcomes after R0 gastrectomy.

METHODS

Eighty-six consecutive patients undergoing R0 gastrectomy for adenocarcinoma were studied. Normal gastric mucosa and tumor were stained for gastrin and their specific cellular distribution was determined.

RESULTS

The duration of survival of patients whose tumors exhibited well-differentiated gastrin-positive tumor (GPT) cells (n = 12) was significantly poorer than that of patients whose tumors were GPT-negative (5-year survival, 30% vs 54%; P = 0.037). Patients with GPT-positive intestinal-type gastric cancer (5 of 47 patients) had the poorest survival of all (median, 14 months; 5-year survival, 0%; P = 0.006). In a multivariate analysis, only lymph node metastases (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.2 to 3.79; P = 0.01) and the presence of GPT cells (HR, 6.61; 95% CI, 1.74 to 25.09; P = 0.01) were independently and significantly associated with durations of survival in patients with intestinal-type gastric cancer.

CONCLUSION

The presence of GPT cells in patients with gastric adenocarcinoma is a significant and independent prognostic indicator.

Prognostic significance of alarm symptoms in patients with gastric cancer

BACKGROUND

The aim of this study was to determine the incidence and spectrum of alarm symptoms in patients with newly diagnosed gastric cancer, and to examine the relationship between symptoms and outcome.

METHODS

Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively. The outcomes of 40 patients (13.3 per cent) without alarm symptoms (21 men; median age 69 years) were compared with those of the 260 patients (86.7 per cent) with alarm symptoms (175 men; median age 72 years).

RESULTS

It was possible to perform an R0 gastrectomy more often in patients without alarm symptoms (21 patients; 52 per cent) than in those with alarm symptoms (71 patients; 27.3 per cent) (chi(2) = 10.35, 1 d.f., P = 0.001). The cumulative survival rate at 5 years was 38 per cent for patients without alarm symptoms versus 15.0 per cent for those with alarm symptoms (chi(2) = 10.18, 1 d.f., P = 0.001). In a multivariate analysis, distant metastasis (hazard ratio (HR) 2.73 (95 per cent confidence interval (c.i.) 2.04 to 3.66); P < 0.001), overall stage of cancer (HR 1.83 (95 per cent c.i. 1.53 to 2.19); P < 0.001) and persistent vomiting at diagnosis (HR 1.66 (95 per cent c.i. 1.26 to 2.18); P < 0.001) were independently associated with length of survival.

CONCLUSION

Alarm symptoms are absent in a significant minority of patients with gastric cancer at diagnosis; these patients stand a better chance of curative surgery and long-term survival than those with alarm symptoms.

Dyspepsia in African-American and Hispanic patients

Dyspepsia is a common disorder with a prevalence of up to 40% in the general population. The presence of alarm features (age >50 years, loss of appetite, early satiety, loss of weight, dysphagia, abdominal mass, gastrointestinal bleeding, and/or anemia) increase the likelihood of an organic etiology. Despite a plethora of information written on this subject, the literature is sparse in minority populations. We studied the etiology of dyspepsia in relation to age and the presence or absence of alarm features in 678 African-American and Hispanic patients. Five-hundred-thirty patients were investigated by upper gastrointestinal (UGI) endoscopy, 88 by barium radiographs of the UGI tract, and 60 patients had both endoscopy and barium studies. The most common alarm feature in our study was age >50 years, followed by anemia, weight loss, gastrointestinal bleeding, loss of appetite, early satiety, abdominal mass, and dysphagia. The presence of alarm features and older age increased the likelihood of finding an organic lesion. It is concluded, therefore, that endoscopy in our dyspeptic patients who had alarm features appears to increase the diagnostic yield and may consequently result in a more favorable therapeutic outcome.

The effects of an awareness-raising program for patients and primary care physicians on the early detection of gastro-oesophageal cancer

OBJECTIVE

To test the efficacy of education by home letter, together with improved specialist/GP liaison, in promoting the detection of treatable gastro-oesophageal cancer in patients over 40.

DESIGN

Prospective non-randomized trial with matched control group.

PARTICIPANTS

37,500 individuals over 40, registered with 12 general practices, were sent yearly letters for 3 consecutive years, advising them to consult a doctor with 4 specific symptoms. A matched control population of 60,500 received no intervention.

MAIN OUTCOME MEASURES

Cancer cases were identified from cancer registry data, and the stage distribution and operability rates calculated from review of hospital case notes.

RESULTS

Twenty of 59 cancer patients in the study group (34%) and 42 of 125 in the control group (34%) underwent resections; 24% (14/59) of study group and 18% (23/125) of control patients had "curable" disease (odds ratio [OR]= 1.51 [95%CI 0.71-3.23], X(2) = 1.164, P = 0.28). In year 1 of the study, 11 of 20 (55%) study group patients underwent resection compared to P 10 of 38 (26%) control group patients (P = 0.045, Fisher's exact test, OR = 3.4 [95% CI 1.09-0.7]). In year 1, 8 of 20 study patients (40%) had "curable" disease compared to 10.5% (4/38) control patients (P = 0.0128 Fisher's exact test, OR = 5.67 [95% CI 1.44 - 22.3]). There was no difference in survival between the groups overall or on comparing each year of study.

CONCLUSION

This intervention caused a transient marked improvement in resection rate and curability, but the longer term impact on stage and resection rate was nonsignificant, and survival was not affected. Improving the detection of curable upper GI cancer is likely to require more complex and intensive interventions.

A rational approach to uninvestigated dyspepsia in primary care: review of the literature

In this paper the rationale and limitations of the four most important approach strategies to dyspepsia in primary care (empiric treatment, prompt endoscopy, "test-and-scope", and "test-and-treat") are analysed. It is concluded that in the absence of alarm symptoms, a "test-and-treat" approach is currently the most rational approach provided that three conditions are met: (1) a highly accurate test should be used, (2) the prevalence of Helicobacter pylori in the population should not be too low, and (3) an effective anti-H pylori regimen should be prescribed taking sufficient time to instruct and motivate the patient.

Long-term safety of proton pump inhibitors: risks of gastric neoplasia and infections

After Helicobacter pylori eradication was introduced and largely eliminated the need for maintenance therapy for peptic ulcer disease, gastroesophageal reflux disease (GERD) became the main indication for prolonged gastric acid inhibition. The drug effect on GERD depends on the degree of acid inhibition, thus the efficacious proton pump inhibitors are preferred. The proton pump inhibitors have few immediate side effects, the main concern being the profound hypoacidity and hypergastrinaemia they induce. In short-term, hypergastrinaemia causes rebound hyperacidity, possibly worsening GERD and reducing the efficacy of histamine H(2) blockers. In the long-term, hypergastrinaemia causes enterochromaffin-like cell hyperplasia and carcinoids. Since enterochromaffin-like cells may be important in gastric carcinogenesis, iatrogenic hypergastrinaemia may predispose to carcinoma. Gastric hypoacidity also increases gut bacterial infections, and the barrier function of acid against viral and prion infections requires further assessment.

A review of epidemiological studies on cancer in relation to the use of anti-ulcer drugs

H2-receptor antagonists have been widely used since the late 1970s for the treatment of gastrointestinal ulcers and other benign conditions of the stomach, oesophagus and duodenum. Several case reports suggested that long-term therapy with H2-receptor antagonists, mainly cimetidine and ranitidine, might increase the risk of gastric cancer. After early case reports, at least six analytical epidemiological studies (two cohort and four case-control) were published, including a total of about 1000 cases of gastric cancer. The relative risks (RR) were systematically and substantially elevated in the first year since starting H2-receptor antagonist use, and levelled off in the following years. Some excess risk was still apparent during the first 5 years of drug use, probably due to incorrect diagnosis and treatment of pre-existing neoplastic gastric lesions, but the estimated RR was not above unity for > or = 10 years since starting drug treatment in the two studies including information on long-term use. The findings of analytical epidemiological studies are thus consistent with the absence of a causal association between H2-receptor antagonist use and gastric cancer risk. Data on oesophageal and colorectal cancer do not support a relevant relation between cimetidine use and the risk of these neoplasms. With reference to total cancer mortality, in a Danish cohort study, for males the RR was 1.9 in the first year, and 1.4 in the first 5 years; corresponding values for females were 1.7 and 1.5. In a British cohort study, the RR was 3.4 in the first year, and 1.3 in the years 2-10. The excess risk in the first year was essentially due to gastric cancer. Post-marketing surveillance data for omeprazole and other proton pump inhibitors are much scantier than for H2-receptor antagonists, particularly on long-term use.

Proton pump inhibitors: perspectives of patients and their GPs

BACKGROUND

There is growing concern with the rapid increase in prescribing proton pump inhibitor drugs (PPIs) for a variety of gastrointestinal disorders, and the escalating costs associated with this trend. Explanations have included that general practitioners (GPs) prescribe PPIs inappropriately and that patients demand PPIs and use them as a way of avoiding having to make lifestyle changes.

AIM

To compare the perspectives of GPs and their patients on the need for PPIs, to examine the pressure to prescribe, and to examine the effect of PPIs on lifestyle.

DESIGN OF STUDY

Qualitative comparative study based on semi-structured interviews.

SETTING

Twenty-six GPs in seven practices in the West Midlands and 82 of their patients on repeat prescriptions for PPIs.

METHOD

Interviews were conducted covering a wide range of topics, including: experience, cause, course, and outcome of stomach problems; effectiveness of PPIs; and role of lifestyle in controlling symptoms. The transcripts were studied repeatedly to look for the occurrence and distribution of material relating to these issues, as well as other responder-driven issues. Codebooks were devised to enable a simple categorisation and systematic comparison of cases.

RESULTS

GPs and patients agreed about the severity and unpleasantness of stomach symptoms for which PPIs were prescribed. While GPs and patients regarded PPIs as a very effective treatment, GPs rated their efficacy more highly than patients. Half of the GP interviews reproduced the stereotype of the demanding patient and of patients using PPIs to support unhealthy lifestyles. There was little evidence from patient interviews to support either stereotype. Doctors underestimated patient concerns about side-effects, safety, and long-term use of PPIs, and the willingness of patients to achieve the minimum effective dose by experimenting with their treatment. GPs felt that the pressure to prescribe PPIs was outweighed by the pressure not to prescribe, and most GPs had responded to the call to cut the prescribing of PPIs. Different strategies were employed to cut prescribing, including the wholesale switching of patients on a treatment dose of one brand of PPI to a maintenance dose of a cheaper brand of PPI, known as 'double switching'.

CONCLUSION

The stereotypes of 'profligate prescriber', 'demanding patient', and 'adverse lifestyle', as explanations for the increase in the prescribing of PPIs, were not upheld. The stereotype of patients demanding PPIs may arise from GPs' internal pressure to prescribe being externalised onto patients. The extent to which health behaviour contributes to gastric disorders needs to be established empirically. Labelling PPI patients as having a poor lifestyle may be used as a means of reducing legitimate need for PPIs. Current policy relating to switching of dose and brand of PPI should be reviewed.

Strategies for reducing the prescribing of proton pump inhibitors (PPIs): patient self-regulation of treatment may be an under-exploited resource

Escalating costs of proton pump inhibitor (PPI) prescribing are a source of increasing concern. To reduce costs, GPs in the UK have been coming under pressure to restrict PPI prescribing in primary care, e.g. by raising the prescribing threshold for new patients, and encouraging established patients to accept a reduced dose, if not stop taking PPIs altogether. The need to reduce prescribing costs impacts on patients by redefining, i.e. reducing, the boundaries of clinical need for which PPI prescribing is deemed appropriate. This may be rationalised by the assumptions that much existing prescribing is inappropriate, is applied to relatively minor and trivial afflictions, and that patients put pressure on their doctors to initiate prescribing of PPIs, after which they are very reluctant to give them up. The research involved extended interviews to elicit GP and patient views and experience of PPI prescribing. A particular focus was a comparison of the views of patients and GPs, and the understanding and articulation of the patient perspective on PPIs, which has been largely absent from the discussion to date. The research identified six distinct strategies used by GPs in their efforts to reduce PPI prescribing. Contrary to what GPs often assumed to be the case, patients were generally quite receptive to changes to their medication, provided they had the security of knowing that their original prescription would be restored if necessary. Most doctors assessed their rationing strategies as having some impact, but acknowledged the difficulties in achieving a significant and sustained reduction in PPIs. In the study sample nearly half of the patients who had experienced a prescribing switch or step down had drifted back to their former brand, and, especially, higher dose. However, far from being overly and unreflectively dependent on PPIs, patients were often keen to reduce their medicine taking to a minimum. A number of respondents had taken the initiative in experimenting to find the lowest effective dose of PPIs required to control their symptoms. GPs varied in their attitudes to this form of treatment self-management, but less than half actively encouraged patients to regulate their treatment in this way. Our findings suggest that there is considerable scope for encouraging patients to self-regulate with PPIs, and that many patients would be willing to do this if the practice was sanctioned by their doctors. The anticipated benefits of increased self-regulation include an overall reduction in PPI prescribing and associated costs, and an increase in patient autonomy and control which is in line with the concordance model of the ideal relationship between patients and doctors.

Overuse of proton pump inhibitors

BACKGROUND

There have been concerns raised about the potential adverse effects of proton pump inhibitors, especially with long-term use. In particular, their potent action can suppress the features and delay the diagnosis of gastric cancer, while prolonged exposure may hasten the development of gastric carcinoids.

AIM

To examine the use of proton pump inhibitors in patients at the major teaching hospital in Tasmania, Australia, principally to determine the appropriateness of the therapy according to published guidelines.

METHODS

A retrospective review of the medical records of all patients prescribed any of the proton pump inhibitors at the hospital over a 7-month period, was performed. An extensive range of demographic and clinical variables was recorded for each patient. The patients were also asked a series of questions during their hospitalization to extract some of the relevant information - in particular, if and when they had undergone endoscopy.

RESULTS

The 200 patients (52% males) had a mean age of 69 +/- 16.4 years. The most common indications for using proton pump inhibitors were acute gastrointestinal bleeding (20.9%), severe refractory ulcerating oesophagitis (17.3%), mild/moderate oesophageal reflux (17.3%) and refractory peptic ulcer (11.7%). A large number of patients were using a proton pump inhibitor for 'other' indications (39.6%). The prescribing of proton pump inhibitors satisfied the approved indications, as outlined in the Australian Schedule of Pharmaceutical Benefits, in only 37.1% of cases. Endoscopy had been performed in 54.1% of patients prior to commencing therapy with a proton pump inhibitor and within the next 7 days in another 12.8% of patients. Only 59% of patients had previously been treated with an H2-receptor antagonist before commencing therapy with a proton pump inhibitor. Even worse, only 58.5% of patients had used an H2-receptor antagonist before a proton pump inhibitor for mild/moderate oesophagitis. The median duration of proton pump inhibitor therapy for patients admitted to the hospital and already receiving one of the drugs was 450 days. Over half of the patients were being concurrently treated with other drugs which are known to cause or exacerbate gastro-oesophageal disease, and 18% were smokers.

CONCLUSION

Whereas the proton pump inhibitors are undoubtedly effective agents, studies of their prescribing in practice consistently suggest over-use prior to endoscopy, use in patients who do not fit the approved criteria, and prescribing for indications in which 'less powerful' agents should have been sufficiently effective for the patient's symptoms. This poses economic and safety concerns, particularly in light of the suggestion that these drugs could delay the diagnosis of gastric cancer.

A comparison of open access endoscopy and hospital-referred endoscopy in a district general hospital

Open access endoscopy (OAE) is widely used in many hospitals. The aim of this study was to compare the upper gastrointestinal endoscopies referred to as "OGDs" performed under the OAE service and those referred from hospital outpatient clinics (HR) during the initial year in which an OAE service was provided in a district general hospital. A retrospective review of medical records from all patients undergoing OGD during the first year of OAE to identify the waiting time for OGD, the extent of pre-treatment at the time of OGD, the endoscopic findings and the number of endoscopies in which oesophageal or gastric neoplasia was detected. Follow-up endoscopies (n = 41) were excluded. Of 739 OGDs included, 384 (177 male; mean age 48.0 yrs.) were performed under the OAE service, 346 (149 male; mean age 50.7 yrs.) were referred from outpatient clinics and 9 could not be accurately classified. The waiting time was significantly lower in the OAE group compared to the HR group (24.5 v. 29.8 days, p<0.001). Pre-treatment at the time of OGD was significantly more frequent in the OAE group compared to the HR group (295 v. 186, p<0.001). Frequencies of the main endoscopic diagnoses did not differ significantly between the two groups. The OAE service provided faster access to OGD than the HR group and the endoscopic findings were similar in the two groups.

Pantoprazole, Prout and the proton pump

Pantoprazole is a proton pump inhibitor which has recently had its clinical license extended to include maintenance therapy for the treatment of reflux oesophagitis, Helicobacter pylori eradication and short-term intravenous administration. This article reviews the history of gastric acid secretion and examines the role of proton pump inhibitors, particularly pantoprazole, in the treatment of acid-related disorders.