Treatment with cimetidine, antacid, or placebo in patients with dyspepsia of unknown origin

Systematic review and network meta-analysis: efficacy of drugs for functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a relapsing and remitting condition affecting between 5% and 10% of people. Efficacious therapies are available, but their relative efficacy is unknown.

AIM

To perform a systematic review with network meta-analysis to resolve this uncertainty.

METHODS

We searched the medical literature through July 2020 for randomised controlled trials (RCTs) assessing efficacy of drugs for adults with FD, compared with each other, or placebo. Trials reported a dichotomous assessment of symptom status after completion of therapy. We pooled data using a random effects model. Efficacy was reported as a pooled relative risk (RR) of remaining symptomatic with a 95% confidence interval (CI) to summarise efficacy of each comparison tested. Relative ranking was assessed with surface under the cumulative ranking curve (SUCRA) probabilities.

RESULTS

We identified 71 eligible RCTs (19 243 participants). Tricyclic antidepressants (TCAs) were ranked second for efficacy (RR of remaining symptomatic = 0.71; 95% CI 0.58-0.87, SUCRA 0.87), and first when only low risk of bias trials were included. Most RCTs that used TCAs recruited patients who were refractory to other drugs included in the network. Although sulpiride or levosulpiride were ranked first for efficacy (RR = 0.49; 95% CI 0.36-0.69, SUCRA 0.99), trial quality was low and only 86 patients received active therapy. TCAs were more likely to cause adverse events than placebo.

CONCLUSIONS

TCAs, histamine-2 receptor antagonists, standard- and low-dose proton pump inhibitors, sulpiride or levosulpiride, itopride and acotiamide were all more efficacious than placebo for FD.

[Updated guidelines 2012 for gastroesophageal reflux disease]

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

Review article: current treatment options and management of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89-90%), postprandial fullness (75-88%), and early satiety (50-82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non-specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.

AIM

To present current management options for the treatment of FD (therapeutic gain/response rate noted when available).

RESULTS

The utility of Helicobacter pylori eradication for the treatment of FD is modest (6-14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7-10% therapeutic gain), histamine-type-2-receptor antagonists (8-35% therapeutic gain), prokinetic agents (18-45%), tricyclic antidepressants (TCA) (response rates of 64-70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.

CONCLUSIONS

A reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori-negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti-nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.

[Guidelines for the treatment of functional dyspepsia]

Functional dyspepsia (FD) is defined as the presence of symptoms thought to originate in the gastroduodenal area, in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms. Based on the available evidence and consensus opinion, thirteen consensus statements for the treatment of FD were developed using the modified Delphi approach. Proton pump inhibitor, prokinetics, and histamine 2 receptor antagonists are effective for the treatment of FD. Mucosal protecting agents, fundus relaxant, and drugs for visceral hypersensitivity can improve symptoms in FD. Antacids and antidepressants may help improving symptoms in FD. Comparing endoscopy with 'test and treat' of Helicobacter pylori, endoscopy may be more effective initial strategy for managing patients with FD in Korea given high incidence of gastric cancer and low cost of endoscopy. Helicobacter pylori eradication can be one of the therapeutic options for patients with FD. Psychotherapy is effective for those who have severe symptoms and refractoriness. Further studies are strongly needed to develop better treatment strategies for Korean patients with FD.

Efficacy of a simethicone, activated charcoal and magnesium oxide combination (Carbosymag®) in functional dyspepsia: results of a general practice-based randomized trial

BACKGROUND

A simethicone, activated charcoal and magnesium oxide combination (Carbosymag(®)) has been used for almost 20 years in functional dyspepsia, but there is limited scientific evidence of efficacy.

AIM

We evaluated the efficacy of Carbosymag(®) in 18- to 49-year-old patients with functional dyspepsia.

METHODS

A total of 276 dyspeptic patients consulting a general practitioner and meeting the Rome III criteria were included in this prospective placebo-controlled study. Variations in overall and individual dyspeptic symptoms were evaluated after 1 month of treatment.

RESULTS

At the end of the treatment period, overall dyspeptic symptom intensity was significantly lower in the Carbosymag(®) group (P=0.01). The intensity of post-prandial fullness, epigastric pain, epigastric burning and abdominal bloating was significantly reduced in the Carbosymag(®) group relative to the placebo group (P<0.05). The number need to treat to induce a 70-% decrease in overall dyspeptic symptoms by Carbosymag(®) was 7 (IC 95%: 4-32).

CONCLUSION

A simethicone, activated charcoal and magnesium oxide combination (Carbosymag(®)) was significantly more effective than a placebo on overall symptom intensity in dyspeptic patients consulting a general practitioner.

Review article: endpoints used in functional dyspepsia drug therapy trials

BACKGROUND

The measurement of patient-reported outcomes (PRO) in treatment trials for functional gastrointestinal disorders is a matter of controversy.

AIM

To focus on instruments and endpoints that have been used to evaluate the efficacy of therapeutic agents in functional dyspepsia (FD) trials, also considering the newly defined Rome III FD criteria.

METHODS

A Medline search was conducted to identify relevant studies pertaining to FD treatment, with particular emphasis on the studies to date which have used validated outcome measures.

RESULTS

Currently available outcome measures are heterogeneous across studies. They include global binary endpoints, analogue or categorical scoring scales, uni- or multi-dimensional disease specific questionnaires, global outcome evaluations and quality of life questionnaires. Across the available outcome measures, substantial heterogeneity is found, not only in the type of endpoint measure, but also in the number and types of symptoms that are considered to be part of the FD symptom complex. Especially based on content validity, none of the existing questionnaires or endpoints can be considered sufficiently validated to be recommended unequivocally as the primary outcome measure for FD trials according to the Rome III criteria. On the other hand, existing well-validated multi-dimensional questionnaires that include many non-FD symptoms can be narrowed down to evaluate only the cardinal symptoms according to Rome III.

CONCLUSIONS

There is an urgent need to develop Rome III-based patient-reported outcomes for functional dyspepsia. Well-validated multi-dimensional questionnaires may serve as a guidance for this purpose, and could also be considered for use in ongoing clinical trials.

WITHDRAWN: Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that £450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

The Success of Histamine-2 Receptor Antagonists

The lives of both patients and doctors have been revolutionized since the development of histamine-2 receptor antagonists. Their development has introduced, for the first time, a rapid, reliable, and save means of healing both duodenal and gastric ulceration. The continuous administration of these agents has additionally been shown to reduce ulcer relapse and subsequent complications. In addition, they offer some protection from the development of nonsteroidal anti-inflammatory drug-induced damage. The symptomatic relief of reflux together with healing of oesophagitis has been of further benefit. The drugs in this group have become one of the most widely used ethical pharmaceuticals in the world, with ranitidine (Zantac) as the biggest-selling drug in the world for the last few years. Their success can be attributed to their simplicity of use, safety, and above all, their efficacy. Their current role in gastroenterologic practice, in the face of new developments such as Helicobacter eradication and the development of proton pump inhibitors, will be discussed.

Functional Dyspepsia: A New Rome III Paradigm

Functional dyspepsia (FD) is a condition commonly seen in gastroenterological practice. With the introduction of Rome III criteria in 2006, a new approach for categorizing patients has been recommended. The diagnostic criteria suggest that meal-related and pain-predominant symptom groupings that presumably have distinct pathophysiologic mechanisms and potentially different therapeutic targets exist. The new classification is in the early stages of testing; in the meantime, the umbrella term of FD should continue to be utilized in clinical practice. Treatment of FD remains a major challenge. Unfortunately, most of the agents used in practice have limited or no evidence of efficacy, and the results typically are short-lived once therapy is ceased. Appropriate therapy currently is based on a consideration of putative pathophysiologic mechanisms. Testing for and eradicating Helicobacter pylori is a first-line strategy irrespective of the symptom pattern. In patients who have epigastric pain, antisecretory agents are recommended. Antacids, bismuth, and sucralfate seem to be no better than placebo. For meal-related symptoms such as postprandial fullness or early satiety, prokinetics may confer some benefit. However, few choices are available, and the efficacy for those drugs on the market is limited at best. Antidepressants are of uncertain efficacy but are widely used. Psychological therapies seem promising and may confer benefits on both pain and meal-related symptoms. Efficacy of complementary medicines has been suggested in controlled trials, but more data are needed. Emerging treatments include gastric fundus relaxors and visceral analgesics, although their application in FD is still in the preliminary stages.

Non-ulcer dyspepsia: myths and realities

Dyspepsia can be defined as the presence of upper abdominal pain or discomfort; other symptoms referable to the proximal gastrointestinal tract, such as nausea, early satiety, and bloating, may also be present. Symptoms may or may not be meal related. To be termed chronic, dyspepsia should have been present for three months or longer. Over half the patients who present with chronic dyspepsia have no evidence of peptic ulceration, other focal lesions, or systemic disease and are diagnosed as having non-ulcer (or functional) dyspepsia. Non-ulcer dyspepsia is a heterogeneous syndrome. It has been proposed that this entity can be subdivided into a number of symptomatic clusters or groupings that suggest possible underlying pathogenetic mechanisms. These groupings include ulcer-like dyspepsia (typical symptoms of peptic ulcer are present), dysmotility (stasis)-like dyspepsia (symptoms include nausea, early satiety, bloating, and belching that suggest gastric stasis or small intestinal dysmotility), and reflux-like dyspepsia (heartburn or acid regurgitation accompanies upper abdominal pain or discomfort). The aetiology of non-ulcer dyspepsia is not established, although it is likely a multifactorial disorder. Motility abnormalities may be important in a subset of dyspepsia patients but probably do not explain the symptoms in the majority. Epidemiological studies have not convincingly demonstrated an association between Helicobacter pylori and non-ulcer dyspepsia. Other potential aetiological mechanisms, such as increased gastric acid secretion, psychological factors, life-event stress, and dietary factors, have not been established as causes of non-ulcer dyspepsia. Management of non-ulcer dyspepsia is difficult because its pathogenesis is poorly understood and is confounded because of a high placebo response rate. Until more data are available, it seems reasonable that treatment regimens target the clinical groupings described above. Antacids are no more effective than placebo in non-ulcer dyspepsia, although a subgroup of non-ulcer dyspepsia patients with reflux-like or ulcer-like symptoms may respond to H2-receptor antagonists. However, there is no significant benefit of these agents over placebo in many cases. Bismuth has been shown to be superior to placebo in patients with H. pylori in a number of studies, but these trials had several shortcomings and others have reported conflicting findings. Sucralfate was demonstrated in one study to be superior to placebo, but this finding was not confirmed by another group of investigators. Prokinetic drugs appear to be efficacious, and may be most useful in patients with dysmotility-like and reflux-like dyspepsia.

Treatment of endoscopy-negative NSAID-induced upper gastrointestinal symptoms with cimetidine: an international multicentre collaborative study

In this double-blind multicentre trial, 127 patients on non-steroidal anti-inflammatory drugs (NSAIDs) who experienced gastrointestinal symptoms significant enough to warrant endoscopic evaluation, but without endoscopic evidence of mucosal damage, were randomized to receive cimetidine 400 mg b.d. or placebo for 4 weeks. Non-steroidal anti-inflammatory drug therapy was maintained at pre-trial doses for the duration of the study. After 4 weeks, 72% of cimetidine-treated patients experienced complete symptom resolution, as defined by a global symptom score of zero, compared with 49% on placebo. Complete disappearance of upper abdominal pain was achieved in 72% of the cimetidine-treated patients as opposed to 47% on placebo. Relief of heartburn was experienced by 87% of patients on cimetidine compared with 60% on placebo. Throughout treatment, the proportion of cimetidine-treated patients with nausea was consistently lower than in patients on placebo, while the two groups were similar with respect to disappearance of vomiting. At the completion of acute treatment, 27% of placebo-treated patients but only 12% of those on cimetidine were ineligible to continue maintenance due to persisting gastrointestinal symptoms. Patients who were symptom-free and required continuation of NSAID therapy were followed for 6 months during which they were re-randomized to receive cimetidine 400 mg nocte or placebo. Of the 105 patients included in this maintenance treatment phase of the study, 11% of the cimetidine-treated patients and 10% of those on placebo experienced relapse of symptoms. However, the mean time to relapse was 120 days with cimetidine compared with 35 days with placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacological interventions for non-ulcer dyspepsia

BACKGROUND

The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that pound450 million is spent on dyspepsia drugs in the UK each year.

OBJECTIVES

This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H(2) antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006), EMBASE (1988 to January 2006), CINAHL (1982 to January 2006), SIGLE, and reference lists of articles. We also contacted experts in the field and pharmaceutical companies. Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 73 trials: prokinetics (19 trials with dichotomous outcomes evaluating 3178 participants; relative risk reduction (RRR) 33%; 95% confidence intervals (CI) 18% to 45%), H(2)RAs (12 trials evaluating 2,183 participants; RRR 23%; 95% CI 8% to 35%) and PPIs (10 trials evaluating 3,347 participants; RRR 13%; 95% CI 4% to 20%) were significantly more effective than placebo. Bismuth salts (six trials evaluating 311 participants; RRR 40%; 95% CI -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial evaluating 109 participants; RRR -2%; 95% CI -36% to 24%) and sucralfate (two trials evaluating 246 participants; RRR 29%; 95% CI -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic results could be due to publication bias or other small study effects.

AUTHORS' CONCLUSIONS

There is evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so economic analyses would be helpful and ideally the therapies assessed need to be inexpensive and well tolerated.

Review article: current and emerging therapies for functional dyspepsia

Functional dyspepsia represents a heterogeneous group of gastrointestinal disorders marked by the presence of upper abdominal pain or discomfort. Although its precise definition has evolved over the last several decades, this disorder remains shrouded in controversy. The symptoms of functional dyspepsia may overlap with those of other functional bowel disorders including irritable bowel syndrome and non-erosive reflux disease. There may be coexistent psychological distress or disease complicating its presentation and response to therapy. Given the prevalence and chronicity of functional dyspepsia, it remains a great burden to society. Suspected physiological mechanisms underlying functional dyspepsia include altered motility, altered visceral sensation, inflammation, nervous system dysregulation and psychological distress. Yet the exact pathophysiological mechanisms that cause symptoms in an individual patient remain difficult to delineate. Numerous treatment modalities have been employed including dietary modifications, pharmacological agents directed at various targets within the gastrointestinal tract and central nervous system, psychological therapies and more recently, complementary and alternative treatments. Unfortunately, to date, all of these therapies have yielded only marginal results. A variety of emerging therapies are being developed for functional dyspepsia. Most of these therapies are intended to normalize pain perception and gastrointestinal motor and reflex function in this group of patients.

Treatment of functional dyspepsia

Functional dyspepsia (FD) is a common reason a patient presents with upper gastrointestinal symptoms for medical care. Although treatment of FD remains expensive, the agents are rarely used in a systematic manner; the majority of treatments are empirical and the results short lived once therapy is ceased. This is partly due to the lack of consistent pathophysiologic markers in FD, so therapy is symptom driven. This review appraises the best evidence on available interventions. A structured scheme for deciding on appropriate therapies is to consider the possible putative pathophysiologic mechanisms. Eradicating Helicobacter pylori, if present, is a first-line strategy. In patients who have symptoms suggesting excessive gastric acid secretion, particularly epigastric pain, antisecretory agents are recommended. Prokinetics may confer benefits on symptoms suggestive of upper gastrointestinal dysmotility, like fullness or early satiety. However, their use is limited due to availability issues. The expanding field of psychologic therapies provides a promising avenue of treatment. Complementary medicines are now widely use and their benefits have been suggested in recent controlled trials. Emerging treatments include cholecystokinin 1 blockers, opioid receptor agonists, and serotonergic agents, although their application in FD is in the preliminary stages.

Management of functional dyspepsia: Unsolved problems and new perspectives

The common characteristic criteria of all functional gastrointestinal (GI) disorders are the persistence and recurrence of variable gastrointestinal symptoms that cannot be explained by any structural or biochemical abnormalities. Functional dyspepsia (FD) represents one of the important GI disorders in Western countries because of its remarkably high prevalence in general population and its impact on quality of life. Due to its dependence on both subjective determinants and diverse country-specific circumstances, the definition and management strategies of FD are still variably stated. Clinical trials with several drug classes (e.g., proton pump inhibitors, H2-blockers, prokinetic drugs) have been performed frequently without validated disease-specific test instruments for the outcome measurements. Therefore, the interpretation of such trials remains difficult and controversial with respect to comparability and evaluation of drug efficacy, and definite conclusions can be drawn neither for diagnostic management nor for efficacious drug therapy so far. In view of these unsolved problems, guidelines both on the clinical management of FD and on the performance of clinical trials are needed. In recent years, increasing research work has been done in this area. Clinical trials conducted in adequately diagnosed patients that provided validated outcome measurements may result in better insights leading to more effective treatment strategies. Encouraging perspectives have been recently performed by methodologically well-designed treatment studies with herbal drug preparations. Herbal drugs, given their proven efficacy in clinical trials, offer a safe therapeutic alternative in the treatment of FD which is often favored by both patients and physicians. A fixed combination of peppermint oil and caraway oil in patients suffering from FD could be proven effective by well-designed clinical trials.

Treatment of Functional Dyspepsia

Functional dyspepsia is a common chronic condition. It can have a major impact on quality of life and remains a large burden on healthcare resources. Its underlying mechanisms are not fully understood and therapies are mainly empirical. In this review, we summarize the best evidence on available therapeutic interventions in functional dyspepsia. Helicobacter pylori eradication, for those infected, is likely a safe and cost-effective strategy but benefits only a minority. Antisecretory agents such as proton-pump inhibitors and histamine-2 receptor antagonists have shown some benefit and are recommended as the first-line option in the absence of H. pylori infection. There is a lack of strong evidence of benefit from prokinetic agents, and cisapride, the most studied agent, is largely unavailable. Antidepressants need to be adequately tested in functional dyspepsia, but both psychotherapy and hypnotherapy interventions have shown promising results. Herbal therapies need further study in these patients. 5-Hydroxytryptamine3 (5-HT(3)) and 5-HT(4) receptor antagonists, and cholecystokinin type A and neurokinin receptor antagonists remain promising emerging therapies.

Systematic review: the methodological quality of trials affects estimates of treatment efficacy in functional (non-ulcer) dyspepsia

AIM

To evaluate treatment efficacy using objective quality criteria.

METHODS

A systematic review was performed of randomized controlled trials of endoscopically investigated dyspepsia (1979-2003) using the Jadad score and Rome II guidelines. The Jadad score differentiated studies as 'high quality' (score 4-5/5) vs. 'poor quality' (score 1-3/5). Three key Rome II guidelines on study design (cut-off of 0/3 or > 0/3) were also compared with the Jadad score.

RESULTS

Poor quality trials suggested a benefit of prokinetic therapy [relative risk (RR) of remaining dyspeptic, 0.47; 95% confidence interval (CI), 0.39-0.56), which was not confirmed in high quality trials (RR, 1.0; 95% CI, 0.84-1.19). There was a marked benefit of H2-receptor antagonist therapy in poor quality trials (RR, 0.68; 95% CI, 0.61-0.76), but a marginal benefit in good quality trials (RR, 0.87; 95% CI, 0.79-0.97). Trial quality did not affect the small statistically significant benefit seen with Helicobacter pylori eradication. Two high quality trials suggested a limited benefit with the use of proton pump inhibitors, with no poor quality trials to provide a comparison. Separation of the studies by the Rome II criteria had a similar impact on the calculated treatment estimates.

CONCLUSIONS

The magnitude of benefit of prokinetic and H2-receptor antagonist therapies reported in previous meta-analyses has been over-estimated. The quality of trials has an impact on the efficacy estimates of treatment. The Rome II criteria for study methodology may be appropriate for judging study quality.

Systematic review: Antacids, H2-receptor antagonists, prokinetics, bismuth and sucralfate therapy for non-ulcer dyspepsia

BACKGROUND

Evidence for the effectiveness of antacids, histamine-2 receptor antagonists, bismuth salts, sucralfate and prokinetic therapy in non-ulcer dyspepsia is conflicting.

AIM

To conduct a systematic review evaluating these therapies in non-ulcer dyspepsia.

METHODS

Electronic searches were performed using the Cochrane Controlled Trials Register, Medline, EMBASE, Cinahl and SIGLE until September 2002. Dyspepsia outcomes were dichotomized into cured/improved vs. same/worse.

RESULTS

Prokinetics [14 trials, 1053 patients; relative risk reduction (RRR), 48%; 95% confidence interval (95% CI), 27-63%] and histamine-2 receptor antagonists (11 trials, 2164 patients; RRR, 22%; 95% CI, 7-35%) were significantly more effective than placebo. Bismuth salts (RRR, 40%; 95% CI, - 3% to 65%) were superior to placebo, but this was of marginal statistical significance. Antacids and sucralfate were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic and histamine-2 receptor antagonist results could be due to publication bias.

CONCLUSIONS

The meta-analyses suggest that histamine-2 receptor antagonists and prokinetics are superior to placebo. These data are difficult to interpret, however, as funnel plot asymmetry suggests that the magnitude of the effect could be due to publication bias or other heterogeneity-related issues.

Optimal management of patients with non-ulcer dyspepsia: considerations for the treatment of the elderly

Optimal therapy for patients with non-ulcer dyspepsia still remains elusive. Increasing consensus on the definition of non-ulcer dyspepsia may improve the design of clinical trials and result in more effective therapies for this common condition. This paper reviews the investigation, pathophysiology and therapy of non-ulcer dyspepsia in order to formulate management strategies in the elderly. The best outcome for the patient can be achieved by detailed evaluation, leading to therapy targeted to obvious precipitating factors such as dyspepsia-inducing medications and other aggravating factors such as slow-transit constipation. Prokinetics and, to a lesser extent, H(2) receptor antagonists are the main medications of choice. Cisapride, the best studied prokinetic, has been withdrawn from the market in certain countries because some patients experienced dangerous cardiac arrhythmias, especially when cisapride was given with potent inhibitors of cytochrome P450 3A4. Time spent on reassurance and judicious use of antidepressants for the right patient can help improve symptoms. In the elderly, however, persistent symptoms should be re-evaluated because of the increased incidence of malignancy.

Double-blind placebo-controlled multicentre studies of rebamipide, a gastroprotective drug, in the treatment of functional dyspepsia with or without Helicobacter pylori infection

BACKGROUND

Functional dyspepsia is a problem that is difficult to treat in clinical practice.

AIM

To evaluate the efficacy and safety of rebamipide (a cytoprotective drug) in functional dyspepsia.

METHODS

Patients with functional dyspepsia (n=557) were divided a priori into two studies by Helicobacter pylori status, and enrolled in a 2-week baseline evaluation period. Ninety-nine patients with Helicobacter pylori and 173 patients without Helicobacter pylori, continuing to have at least moderate upper abdominal pain or discomfort, were randomly assigned to rebamipide 100 mg, rebamipide 200 mg or placebo, three times a day, in a double-blind design for 8 weeks.

RESULTS

There was significant improvement of individual symptom scores from baseline in all the treatment arms. No significant improvement of individual symptom scores was observed in either rebamipide group at the end of the studies compared to placebo, although the belching score was significantly reduced in the rebamipide 100 mg and 200 mg groups at week 2 (P=0.017 and P=0.012, respectively) in the Helicobacter pylori-positive patients. The ratio of patients who requested usage of the study medication again was greater in the rebamipide 100 mg (85%) and 200 mg (96%, P=0.020) groups compared with the placebo group (72%) among Helicobacter pylori-positive patients. There were no serious study medication related adverse events.

CONCLUSIONS

Rebamipide was not superior to placebo in terms of individual symptoms at the end of treatment.

H2-receptor antagonists in the treatment of functional (nonulcer) dyspepsia: a meta-analysis of randomized controlled clinical trials

AIM

To perform a meta-analysis evaluating the efficacy of H2-receptor antagonists in functional (nonulcer) dyspepsia.

SELECTION OF STUDIES

A Medline search was used to identify placebo controlled randomized clinical trials, using the subject headings dyspepsia and H2-receptor antagonist.

OUTCOME MEASURES

Global assessment by the patient of dyspepsia symptoms, improvement of epigastric pain and complete relief of epigastric pain.

RESULTS

Twenty-two studies met the inclusion criteria, 15 of which reported the active drug to be superior to placebo. Many studies suffered from suboptimal study design. The odds ratio in favour of active drug was 1.48 (95% confidence interval: 0.9-2.3) for global assessment of dyspepsia symptoms, 2.3 (95% CI: 1.6-3.3) for improvement of epigastric pain, and 1.8 (95% CI: 1.2-2.8) for complete relief of epigastric pain.

CONCLUSION

There is some evidence that H2-receptor antagonists are superior to placebo in functional dyspepsia, but larger studies evaluating higher doses of H2-receptor antagonists and of longer duration are necessary to determine the exact effect size.

Current indications for acid suppressants in dyspepsia

Anti-secretory drug use is common in patients with uninvestigated and functional dyspepsia, but the value of such agents has been controversial. Four large studies have evaluated the symptomatic outcome after a short course of acid inhibition in patients with uninvestigated dyspepsia presenting in primary care. All of these studies demonstrated a superior symptom response to proton pump inhibitor therapy compared with placebo and acid-alginates or H(2)-receptor antagonists. In patients with documented functional dyspepsia, 17 parallel group trials have evaluated an H(2)-receptor antagonist against placebo, with mixed results. A recent Cochrane review based on eight controlled trials concluded that there was a significant benefit of H(2)-blockers over placebo with a relative risk reduction of 30%, but as gastro-oesophageal reflux disease was not excluded, the conclusions are questionable. Six controlled studies have compared symptom relief after a short course of proton pump inhibitor therapy compared with placebo. Overall, there does appear to be a therapeutic gain with proton pump inhibitors over placebo, although how much of this is explained by undiagnosed gastro-oesophageal reflux disease remains unclear. There is conflicting evidence on the value of symptom subgrouping as a predictor of response to acid suppression. Overall, there is little convincing evidence that Helicobacter pylori infection influences the therapeutic outcome of acid-suppressant therapy. In conclusion, there appears to be a subgroup of patients with functional dyspepsia who will respond to acid suppression over and above placebo, but further work is required to characterize these responders.

Motilin- and neuropeptide Y-like immunoreactivity in a psychophysiological stress experiment on patients with functional dyspepsia

BACKGROUND

The aim of the study was to compare plasma motilin-like immunoreactivity (MOT-LI) and neuropeptide Y (NPY)-like immunoreactivity (NPY-LI) in patients with functional dyspepsia (FD) during a controlled psychophysiological experiment.

METHOD

25 patients (12 men, 13 women), age 24-50, with recurrent FD, and 25 pair-wise sex- and age-matched community control subjects were studied. In an experiment, after a rest period, subjects were studied during a 15-min stress interview. The aim of the interview was to elicit anxiety. Before and during the intervention blood samples were drawn for peptide analyses. Outcome measures were the Gastrointestinal Symptom Rating Scale, fasting blood glucose, heart rate and blood pressure as well as the subjects' self-ratings on visual analogue scales. The plasma concentrations of MOT-LI and NPY-LI are given as anti-logarithms.

RESULTS

Mean plasma MOT-LI concentration was 7.3 (CI: 5.7-9.4) pmol/L in the patient group, and 7.9 (CI: 6.1-10.2) pmol/L in the control group. Mean plasma NPY-LI concentration was 14.2 (CI: 12.3-16.4) pmol/L in the patient group, and 13.4 (Cl: 11.8-15.3) pmol/L in the control group. Using ANCOVA (covariates: group, gender, age, body mass index and smoking) MOT-LI was related to lower indigestion symptomatology (p<0.04) and positive change in joyfulness during the interview (p<0.03). In the patient group delta motilin correlated with increased joyfulness (p<0.03) and decreased sadness (p<0.03). The NPY-LI increase during the interview was related to higher fasting blood glucose before the interview (p<0.01) and a stronger increase in systolic blood pressure during the test (p<0.05).

CONCLUSION

During a stress interview plasma MOT-LI is positively related to less indigestion symptomatology and joyfulness, while changes in plasma NPY-LI were positively related to sympathetic nervous system activity, but not to gastrointestinal symptoms.

A systematic overview of the use of diary cards, quality-of-life questionnaires, and psychometric tests in treatment trials of Helicobacter pylori-positive and -negative non-ulcer dyspepsia

BACKGROUND

Our aim was to evaluate the use of diary cards, quality-of-life questionnaires, and psychometric tests in treatment trials of non-ulcer dyspepsia.

METHODS

Data sources were a Medline search (up to 1966) and a manual search of five gastrointestinal journals (up to 1980) for original, randomized, double-blind, placebo-controlled trials with at least 20 patients which evaluated treatment regimens for non-ulcer dyspepsia.

RESULTS

Of the 67 eligible studies, 31 used diary cards. Diary cards were used alone in 15 of the 31 studies (48%), whereas the others (52%) also used a physician assessment. The symptoms assessed by diary cards were epigastric pain (100%), nausea/vomiting (65%), heartburn (52%), belching (39%), regurgitation (29%), fullness (29%), and bloating (23%). Forty-five per cent also recorded antacid use. Severity of outcome measures was assessed by a visual analogue scale in 5 of the 31 studies (16%), Likert scales in 17 studies (55%), and unclear methods in 3 studies (10%). For statistical analysis daily averages of symptoms were used in 5 of the 31 studies (16%), weekly averages in 11 studies (35%), and 2-week intervals during the treatment period in the rest, with some studies using a combination (such as daily and weekly averages). Only 3 of the 31 studies (8%) checked for compliance with diary card data. None of the studies mention anything about missing data and how this was handled. One study evaluated quality of life questionnaires and one evaluated a psychometric test.

CONCLUSIONS

Non-ulcer dyspepsia treatment trials frequently use diary cards but need to be much clearer about how information was obtained and how it was used in the statistical analysis. Not much information is available to comment on the use of quality-of-life questionnaires or psychometric tests for evaluation of outcome measures.

Placebo in functional dyspepsia: symptomatic, gastrointestinal motor, and gastric sensorial responses

OBJECTIVE

Therapeutic trials in functional dyspepsia consistently show a substantial placebo response, but there is no clear explanation for such an effect. Our aim was to evaluate symptomatic, gastrointestinal motor, and gastric sensorial responses to placebo treatment in patients with chronic and severe functional dyspepsia who were part of a therapeutic trial.

METHODS

Thirty patients were treated during 8 wk with placebo (white-colored 8-mm tablets containing cellulose) by mouth, 20 min before breakfast, lunch, and dinner. We quantified the symptomatic response to placebo as a change in global health status, and also as a change in the individual and combined (global symptom index) of a five-symptom complex: upper abdominal pain, nausea, vomiting, bloating/fullness, and early satiety. Gastroduodenal motility, during fasting and postprandially, was evaluated by manometry in all patients pretreatment and in 17 patients posttreatment. Gastric sensitivity to distension was evaluated in 18 patients pretreatment and in five patients posttreatment (all of them clinical responders).

RESULTS

Placebo treatment produced a striking symptomatic improvement; by 8 wk 80% of the patients reported an improved global health status and their global symptom index markedly decreased (23.9+/-1.3 pretreatment vs 9.1+/-1.2; p < 0.05). Placebo increased the number of gastric phases III starting in the antrum during the fasting period (1.1+/-0.1 vs 1.6+/-0.2; p < 0.05). As a group, no significant changes in postprandial gastroduodenal motility were observed after placebo treatment. However, after placebo a significant improvement in the antral motility index (MI) was observed in the subset of patients with antral hypomotility (MI pretreatment: 7.9+/-1.0; MI posttreatment: 11.7+/-0.4; p < 0.05). Before placebo treatment, patients with functional dyspepsia showed increased sensitivity to stepwise distension of the stomach relative to healthy individuals. After 8 wk of placebo treatment sensitivity to distension remained unchanged, even though patients' clinical status was markedly improved.

CONCLUSION

In patients with functional dyspepsia, the symptomatic response to placebo is substantial. Some significant changes were also observed in gastric motility: increase in the gastric phase III number as well as in the postprandial antral motility index in those with hypomotility pretreatment. Remarkably, however, clinical improvement seems to occur independently of detectable changes in gastroduodenal motor activity or gastric hypersensitivity to distension.

Treatment of functional dyspepsia

Many functional dyspepsia treatment trials have until recently suffered from important weaknesses in study design. A major problem has been the low number of studies that have used validated outcome measures. Fortunately, progress has been made in this area. The evidence for the efficacy of antacids, H2-receptor antagonists, omeprazole, domperidone, cisapride and anti-Helicobacter therapy is reviewed. Although several of these have shown benefit, it is unclear whether this may be a result of the inclusion of patients with unrecognized gastro-oesophageal reflux disease. The data on anti-Helicobacter therapy are conflicting.

Nomenclature of dyspepsia, dyspepsia subgroups and functional dyspepsia: clarifying the concepts

There is international agreement that dyspepsia refers to pain or discomfort centered in the upper abdomen. However, the term 'discomfort' has been variably defined. While other symptoms may often be simultaneously present, gastro-oesophageal reflux disease can usually be clearly distinguished by the presence of predominant heartburn. Dyspepsia is a frequent reason for consultation in primary care and in gastrointestinal practice. With the widespread availability and utilization of endoscopy, it has become evident that a structural (or organic) explanation is found in only a minority of patients presenting with dyspepsia. Operationally, functional dyspepsia is defined as persistent or recurrent dyspepsia for 3 or more months in the absence of a clinically identifiable structural disease causing the symptoms. It has been proposed, based on symptoms, that functional dyspepsia be subdivided into symptom subgroups to promote patient homogeneity. The initially proposed 'clustering' of symptoms into ulcer-like and dysmotility-like functional dyspepsia has proved a dismal failure because of the considerable overlap observed, the lack of stability over time and the failure to identify robust pathophysiological abnormalities or responses to therapy. A subcategorization based upon the most bothersome symptom is theoretically more attractive but needs to be prospectively and rigorously tested.

Antacid (A02A) and antiulcer (A02B) drug prescription patterns: predicting factors, dosage and treatment duration

BACKGROUND

A study is made of the pharmaco-epidemiology of antacid (ATC class A02A) and antiulcer (A02B) drug prescriptions during the year 1992.

METHODS

Prescription data were extracted from 1941 case histories of patients over 15 years old from four health care centers in the Valencian Community (Spain). Dosage and treatment duration were evaluated, along with the way in which morbidity, self-evaluated health, the demographic pattern and life-style characteristics influence drug prescription.

RESULTS

The proportion of drug prescriptions increased with age in both sexes (p < 0.01). Drug use depended mainly on chronic diseases. In prescribing antacids, the most influential diagnosis was gastritis (ICD 534, OR: 157), followed by duodenal ulcer (ICD 532, OR: 152) and gastric ulcer (ICD 531, OR: 122), other gastrointestinal disorders (ICD 66, OR: 54) and undefined diagnoses (OR: 15). In the prescription of antiulcer drugs, the most influential diagnoses were gastric and duodenal ulcer (OR: 380 and 342, respectively), and a significant relation was observed with the diagnosis of osteomuscular diseases (OR: 6). Lifestyle and demographic pattern were of marginal importance. The estimated duration of treatment was 85 days. No significant differences were observed in either treatment duration or administered doses of almagate, ranitidine and omeprazole with respect to sex, age or diagnosis.

CONCLUSIONS

Prolonged treatment is common for acid suppression. The widespread use of peptic ulcer drugs is mostly due to excessive prescription for non-ulcer dyspepsia. At the same time, many patients consume these drugs on a long-term basis in the absence of a clear diagnosis. This observation supports the need for appropriate diagnostic and prescription protocols to secure increased economical savings and management results.

Meta-analysis of antisecretory and gastrokinetic compounds in functional dyspepsia

In view of therapeutic advances, we carried out meta-analysis of results from 18 randomized, controlled clinical studies to update a previous meta-analysis and to provide an overview of clinical trials involving treatment of functional dyspepsia. The studies were included only if they satisfied inclusion and exclusion criteria and assessed treatment of functional dyspepsia with the antisecretory compounds cimetidine and ranitidine and the gastrokinetic compounds cisapride and domperidone. Outcomes of each of these trials were classified in terms of differences in therapeutic success between active treatment and placebo. For antisecretory treatments, the 95% confidence intervals for the difference in therapeutic success between active treatment and placebo were inconsistent for cimetidine, but analysis of both ranitidine trials gave favorable results. For the gastrokinetic compounds cisapride and domperidone, the differences in success rates were generally higher and more in favor of active treatment than placebo. By combining the results from both antisecretory treatments and comparing them with the combined results for gastrokinetic compounds, we observed that gastrokinetic compounds had a greater difference in success rates than did antisecretory agents. Overall, our meta-analysis shows that antisecretory treatment with cimetidine or ranitidine offers little advantage over placebo, whereas gastrokinetic treatment with cisapride or domperidone is significantly better than placebo for treatment of functional dyspepsia.

Gastrin, cholecystokinin, and somatostatin in a laboratory experiment of patients with functional dyspepsia

OBJECTIVE

To explore the pattern of gastrointestinal hormonal variations in plasma and to relate this to possible pathophysiological mechanisms in functional dyspepsia.

METHOD

There were 25 patients, 12 men and 13 women, aged 24 to 50 years, with recurrent functional dyspepsia, compared with community control subjects pair-wise, matched for age and sex. The subjects participated in a laboratory stress experiment with timed provocations. At fixed intervals, 22 samples of blood were drawn from each subject and frozen for later peptide analyses. Levels of gastrin, cholecystokinin (CCK), and somatostatin were measured by radioimmunoassay. Peptide levels were studied during a friendly greeting, a stress interview, and a food stimulation.

RESULTS

Mean hormone values did not differ between the groups. Smokers had lower mean CCK than nonsmokers. Patients with a high degree of dyspeptic symptoms during the week preceding the experiment had a higher mean somatostatin level than patients with a low degree of dyspeptic symptoms. Heartburn correlated positively with the mean somatostatin level. Mean gastrin correlated with body mass index. During the 15-minute stress interview, significant changes in peptide variations were noted: Gastrin increased in both patient and control group subjects. CCK levels increased in patients from 7.2 pmol/l (6.0-8.5) to 9.8 pmol/l (8.2-11.4), but not in control subjects (p < 0.04, two-way interaction). Somatostatin increased significantly earlier in patients than in the control subjects during the stress interview.

CONCLUSIONS

A positive relationship was found between the mean level of somatostatin and the degree of dyspeptic symptoms. Gastrin, CCK, and somatostatin were all sensitive to an anxiety-provoking interview. CCK and somatostatin may possibly link psychological reactions to the pathophysiology of functional dyspepsia.

Clinical economics review: functional (non-ulcer) dyspepsia

Dyspepsia is common within the general population and it imposes a significant burden on health-care resources. Calculation of the economic implications of functional dyspepsia is constrained by the fact that it is only possible to make this diagnosis in a minority of individuals with the disorder, because many do not seek medical attention and investigation is not appropriate for all who do. Studies which attempt to assess the effectiveness or cost-effectiveness of therapy may be further constrained by the fact that there is now good evidence that many patients with dyspepsia seek medical attention not so much because of the severity of symptoms, but because they fear that the symptoms signal the presence of some serious underlying disease. In this situation, effective well-founded reassurance that no serious disease is present is an important outcome of medical intervention and one which should be included in an economic appraisal of dyspepsia management. For obvious reasons, it is sensible to compare the cost-effectiveness of various clinical management strategies applicable in dyspepsia. Decision-tree analyses are currently fashionable but suffer from the major defect that there is no theoretical basis from which patient satisfaction with treatment options can be assessed. It is suggested that for disorders such as functional dyspepsia, which are non-lethal and non-progressive, recommendations about acceptable clinical management strategies require that account be taken of patient satisfaction with the strategies being reviewed. Cost-effectiveness calculations which take no account of this aspect of outcome are of limited relevance to clinical practice.

Management of dyspepsia in general practice. A critical assessment

The International Gastro Primary Care Group (IGPCG) Upper Gastrointestinal Disease Management Plan is mainly characterised by the proposal that management of patients with upper gastrointestinal syndromes be based on the predominant symptom, rather than on symptom clusters. Although no study has directly tested this hypothesis in general practice, some data indirectly support the proposal. Classification based on the relevance of specific symptoms could identify distinct subgroups of patients with functional dyspepsia with at least partially different features. Data obtained from the literature are discussed and evaluated in relation to the suggested algorithm. Overall, this management plan for patients with dyspepsia seems to be both safe and effective. However, there is a need for prospective studies evaluating its actual validity.

Ranitidine effectively relieves symptoms in a subset of patients with functional dyspepsia

BACKGROUND

Acid secretion inhibitors are of dubious value to most patients with functional dyspepsia but might be effective in a subset. The aims of the trial were to compare the effect of ranitidine with that of placebo in selected subsets of patients.

METHODS

Two hundred and twenty-six patients with functional dyspepsia were included in a double-blind multi-crossover (MCO) trial. After 6 weeks an effect score (Xs) with a range of 0-5 was calculated. They were then stratified in accordance with their score and randomized to 4 weeks' double-blind treatment with ranitidine or placebo. Overall symptoms were scored on a 100-mm visual analogue scale, and the change in score (measured in millimetres) was the primary effect measure.

RESULTS

Two hundred and six patients completed the study. The effect of ranitidine and placebo in the 'responders' (76 patients with Xs of 4-5 after the MCO period) was 28 mm and 5 mm, respectively (P < 0.001), and in all patients 19 mm and 12 mm, respectively (P < 0.03). No effect was seen in 'nonresponders' (130 patients with Xs of 0-3 after the MCO period). The clinical improvement, as judged by the patients given ranitidine during the last 4-week period was statistically significantly different in favour of responders compared with nonresponders. We were unable to characterize the responders on the basis of demographics, symptoms, and signs.

CONCLUSIONS

Ranitidine has a good and clinically significant effect in a subset of patients with functional dyspepsia.

Are frequent short gastro-oesophageal reflux episodes the cause of symptoms in patients with non-ulcer dyspepsia responding to treatment with ranitidine?

BACKGROUND

Patients with non-ulcer dyspepsia (NUD) responding to treatment with H2-receptor antagonists have no clinically useful characteristics. This trial compares the gastro-oesophageal reflux pattern as measured by 24-h oesophageal pH monitoring in patients responding to ranitidine with that of non-responders.

METHODS

Thirty-one patients with NUD were randomized to 6 weeks' double-blind alternating treatment with 150 mg ranitidine twice daily or placebo and classified as responders or non-responders.

RESULTS

Pathologic gastro-oesophageal reflux was seen in 3 of the 13 responders and 4 of the 18 no-responders (NS). The responders had frequent short reflux episodes (< 1 min in duration). When 4 patients with > or = 5 reflux episodes longer than 5 min were excluded, the number of short reflux episodes (median) in responders and non-responders was 32 and 14, respectively. The difference is statistically significant (p = 0.025). There were no other differences between the groups.

CONCLUSIONS

In this study patients with NUD responding to ranitidine were characterized by frequent short reflux episodes in the absence of numerous long reflux episodes.

Symptoms and personality in patients with chronic functional dyspepsia

Twenty-five patients, 12 men and 13 women, aged 24-50 yr, who had consulted physicians and had received the diagnosis functional dyspepsia after extensive examination 6-8 years prior to this study, and were still suffering from this condition, were compared with community control subjects pair-wise matched for age and sex. Control subjects who had ever consulted a physician for gastrointestinal symptoms were excluded. Questionnaires measuring symptoms, job strain, social support and personality traits were used. Relatively few differences were found between groups. Compared to the community controls, however, the patients reported more gastrointestinal and nervous symptoms, and higher somatization, measured by Symptom Check List-90. The extent of reported overall distress was greater in patients than in control subjects. The detachment score (Karolinska Scales of Personality) was significantly lower in patients than in control subjects; this difference was also significant in separate analysis for men. Female patients had lower socialization and higher suspicion scores than female control subjects. Male patients reported more decision latitude (job control) than male control subjects.

Aspects of quality of life in gastrointestinal disease: some methodological issues

Quality of Life assessments have many applications in clinical trials. In the evaluation of gastrointestinal disease for example. Quality of Life outcomes provide a useful tool for assessing treatment response. There are a number of standard measures currently available that may be utilized to determine Quality of Life. In clinical trials the use of questionnaires allows the clinician to assess the impact of disease and its subsequent treatment upon the patient's daily life. In order to facilitate comparison of data between studies, it is important that the measures selected are well validated. Patients with gastrointestinal problems do not only experience symptoms. The symptoms have an adverse impact on well-being and ability to enjoy day-to-day activities. It is important to provide appropriate treatment for the large and heterogeneous population with gastrointestinal complaints who have a poor Quality of Life.

Cisapride or cimetidine in the treatment of functional dyspepsia. Results of a double-blind, randomized, Swiss multicentre study

BACKGROUND

Functional dyspepsia is a major diagnostic and therapeutic challenge for the clinician. Several systems for the identification of 'high-risk' patients and classifications of dyspepsia subtypes and treatment schemes have been proposed in the past with limited experimental evidence to support the claims made. The present trial was designed to compare two different treatment modalities in a group of functional dyspepsia patients selected on the basis of a standardized diagnostic procedure as 'non-risk' for organic disease and to assess the result in the major symptom sub-groups of functional dyspepsia as a means of identifying the potential for improving treatment outcome.

METHODS

The efficacy of the prokinetic drug cisapride (5 mg four times daily) and of the histamine H2-receptor antagonist cimetidine (200 mg four times daily) were evaluated after 1 month of treatment and after a further follow-up of 1 month. Patients were randomized to the trial if they fulfilled the following criteria: 1) 'low-risk' symptoms or negative endoscopy findings, and 2) 2 weeks of single-blind antacid treatment did not provide satisfactory relief. For analysis patients were stratified into dyspepsia subtypes.

RESULTS

One hundred and sixty-one patients entered the run-in period, and 137 patients were randomized to the study. At the end of 4 weeks' treatment a small but significant difference in favour of cisapride was found; this difference can mainly be accounted for by the significant difference found in the dysmotility-like subtype (83% improved with cisapride versus 59% with cimetidine). No significant differences could be detected between drugs in the other dyspepsia subtypes at the end of the treatment-or follow-up period.

CONCLUSIONS

The study confirms the classification into dyspepsia-subtypes as a useful tool in selecting the most appropriate drug therapy.

Long term acid suppressing treatment in general practice

OBJECTIVE

To determine the current practice in selected general practices for prescribing long term (> 6 months) treatment to suppress gastric acid secretion.

SETTING

Seven general practices in the Harrow area that always or usually refer to Northwick Park Hospital.

SUBJECTS

60,148 patients on lists of the general practices.

DESIGN

Identification of patients receiving long term treatment through repeat prescribing data, followed by a manual and computer survey of patients' notes for indications and investigations. Patient compliance and views on treatment were sought by a postal questionnaire.

MAIN OUTCOME MEASURES

Indications for treatment, treatment given, investigations undertaken before and during treatment.

RESULTS

492 patients (0.82% of the population) were taking long term acid suppressing treatment. The most common diagnosis was duodenal ulcer disease (183 (37%) of all patients); oesophageal disease (118 (24%)) was also common. 93 patients (19%) were treated for abdominal pain where no diagnosis had been reached or who had only a diagnosis of gastritis on endoscopy. Ranitidine was prescribed in 394 (80%) patients. 298 (74%) patients found treatment helpful, but 108 (27%) had a poor understanding of their diagnosis. 317 patients (78%) took their drug as prescribed. 37 patients were also taking prescribed non-steroidal anti-inflammatory drugs and an additional 43 patients took regular aspirin or ibuprofen without prescription.

CONCLUSIONS

Long term acid suppressing treatment is common, and a substantial number of patients are taking these drugs long term without a diagnosis having been reached. It is hoped that protocols for investigation and treatment will improve these figures. Patients need to be better informed about their disease and the possible adverse effects of taking non-steroidal anti-inflammatory drugs in acid related upper gastrointestinal disease.

Efficacy of sucralfate in treatment of non-ulcer dyspepsia. A double-blind placebo-controlled study

The object of this study was to assess the efficacy of sucralfate in the treatment of non-ulcer dyspepsia (NUD). The diagnosis of NUD was made by exclusion. All patients underwent an upper gastrointestinal endoscopy and abdominal ultrasound, and blood tests were done as clinically indicated. Patients with a history of peptic ulcer disease were not included. Symptomatic assessment was made at the beginning and at the end of the study. The patients registered their most prominent dyspeptic symptoms and whether they improved, were unchanged, or worsened. The study was double-blind. Placebo or 1 g sucralfate four times daily was given for 3 weeks. Over a 2-year period 104 patients were included in the study; 56 received sucralfate and 48 placebo. Nine patients were excluded because of poor compliance or side effects, six from the sucralfate group and three from the placebo group. The sucralfate and placebo groups were comparable with regard to symptom and clinical variables. Global assessment of symptoms showed that in the sucralfate group 34 improved (68%), 11 were unchanged, and 5 were worse. In the placebo group 31 improved (69%), 11 were unchanged, and 3 were worse. There was no statistically significant difference between the groups. The 3-week course of sucralfate in patients with NUD did not show symptomatic improvement over placebo.

Functional dyspepsia. Current treatment recommendations

Symptoms of functional dyspepsia are frequent; the prevalence of dyspepsia (defined as pain or discomfort centred in the upper abdomen) in the general population approaches 25%. By definition, patients with functional dyspepsia do not have a structural or biochemical explanation for their symptoms. Disorders of function (e.g. delayed gastric emptying) are detectable in a proportion of patients but remain poorly understood. Nevertheless, the current rationale for drug treatment is based on altering pathophysiological mechanisms which are believed to be associated with the development of symptoms. Although the placebo response rates approach 60%, prokinetics, acid-suppressing agents and bismuth-containing compounds have been shown to be significantly better than placebo in reducing symptoms. Antacids are widely used, but no controlled study has been able to demonstrate a significant benefit over placebo. The efficacy of sucralfate is uncertain. Rational guidelines on which drug should be used for a given patient are lacking, although approaches based on symptom profiles have been proposed; the duration of treatment needed to achieve long-lasting relief of symptoms is also poorly defined. Identifying optimal treatment for the individual patient, therefore, continues to be largely a trial and error process. Further research efforts are needed to elucidate the pathophysiological basis of functional dyspepsia so that specific therapy can be tailored to underlying pathophysiological disturbances.

The intensity and variability of symptoms in dyspepsia

During the waiting time for upper gastrointestinal endoscopy 165 patients with dyspepsia completed a questionnaire and a diary for daily measurements of the symptoms pain, heartburn, and global complaints. 23 patients (14%) had peptic ulcer disease (PUD), 18 oesophagitis (11%), and the rest were labelled nonulcer dyspepsia (NUD). NUD was further subdivided into ulcer-like, reflux-like, dysmotility, and essential NUD by means of predefined symptom profiles. 39 (24%) patients were on H2 receptor antagonist treatment. In general, the intensity of the daily symptoms was rather low, and except for a higher rating of heartburn in oesophagitis, there were no significant differences between PUD, oesophagitis, and NUD--treated or untreated. NUD patients with reflux-like dyspepsia had significantly more heartburn than the group with essential NUD; otherwise there were no differences between the subgroups of NUD. The individual daily ratings for abdominal pain, heartburn, and global symptoms varied by an average standard deviation of 64%, 97% and 47% of the mean values, respectively, and were independent of treatment or diagnoses. There was an approximately 40% probability that two successive days had different levels of symptoms. Only 10% of the patients showed stable symptoms, and the patients were completely symptom-free for 20% of the observation period. Symptoms in dyspepsia patients disclosed low intensity and high variability in this study. Such factors may be important sources of bias in clinical trials.

Pathophysiology and treatment of functional dyspepsia

Functional dyspepsia (or 'non-ulcer') is usually defined as chronic or intermittent upper abdominal symptoms for which no organic cause can be found. Division of functional dyspepsia into subgroups such as reflux-like, ulcer-like, dysmotility-like and non-specific dyspepsia has been proposed, but lacks a scientific basis. Gastric acid hypersecretion, Helicobacter pylori-associated gastritis, gastric and small intestinal motor disorders, psychological and neurohormonal factors all might play a role in the pathogenesis. The heterogeneity of the underlying abnormalities makes it unlikely that one single treatment modality will ever be beneficial to all patients. In general practice, a therapeutic trial, with either a prokinetic or an acid secretion inhibiting drug, is usually carried out before diagnostic procedures are performed to exclude organic abnormalities. In the choice of the initial therapy, some guidance can be derived from the prominent symptoms. In a study in 30 H. pylori-negative patients with functional dyspepsia ranitidine (150 mg bid) significantly reduced the severity of heartburn. The effect was most pronounced in patients of the reflux-like subgroup.

Eradication of Helicobacter pylori in patients with non-ulcer dyspepsia

Non-ulcer dyspepsia is an unsatisfactory term, as it describes a spectrum of conditions. The term is used for patients who have a normal upper endoscopy, macroscopically, but who have persistent upper gastrointestinal symptoms. Patients with non-ulcer dyspepsia respond to a wide variety of treatments, and there is a strong placebo response. Fifty per cent of these patients are shown to have Helicobacter pylori present if biopsy specimens are taken at endoscopy. Previous studies suggest that H. pylori eradication improves patients' symptoms. In a study from our unit we have shown that, in the short term, patients' symptoms improved with treatment, independent of H. pylori status. However, at 1-year follow-up, prolonged improvement of symptoms was observed only in patients in whom the organism had been eradicated.