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| |  ACG: More Reasons Why Proton Pump Inhibitors Should be First-line Therapy for Dyspepsia By Cameron Johnston Special to DG News LAS VEGAS, NV -- October 29, 2001 -- Doctors should be less concerned about ordering investigative tests, and consider immediate therapy with a proton pump inhibitor, says a researcher from University of Virginia, in Charleston, Virginia. More than 80 percent of patients will respond to treatment with a proton pump inhibitor (PPI) for a wide range of gastrointestinal complaints, explained Dr. David Puera, associate chief of medicine and professor of medicine at the annual meeting of the American College of Gastroenterology (ACG), in Las Vegas, Nevada. He said that patients do consult their family doctors or specialists initially because they have erosive esophagitis, or gastroesophageal reflux disease (GERD), or dyspepsia. They go to their doctors initially because they have symptoms that are affecting their quality of life. "Patients are not disabled because of the erosions in their esophagus -- they are disabled because of symptoms," he said in an exclusive interview with Doctor’s Guide. "Doctors should concern themselves less with ordering investigative studies and get to work treating the patients’ symptoms." Dr. Puera presented the results of a study in which patients were treated with PPIs if they had non-ulcer dyspepsia (NUD). As part of the study protocol, patients were excluded if they had any one of a number of other conditions, including heartburn and upper abdominal discomfort, predominant heartburn with upper gastrointestinal discomfort, gastric and duodenal ulcers, and erosive esophagitis. Out of the 1,886 patients initially screened, 802 (42.5 percent) had NUD, while 1,084 (57.5 percent) had other conditions. Out of those who were categorized as "other", the only ones who would not be expected to respond to PPI therapy were those with irritable bowel, esophageal stricture, functional constipation and gall bladder disease - approximately 11 percent of patients. "In this large population, we didn’t find any severe disease, so I think it’s very satisfying dealing with dyspepsia knowing that the chances are not great that you’ll be dealing with a cancer or anything like that. Since 80 percent of these patients are going to respond to PPIs, just start them, you don’t need to do all that investigative testing." The patients were treated with the PPI lanzoprazole (Prevacid, TAP Pharmaceuticals) 15 mg and 30 mg, and it was found that approximately 40 percent had symptom resolution at four weeks, and 50 percent had resolution at eight weeks. Dr. Puera’s comments seem like a carry-over of the "test-and-treat" for Helicobacter pylori debate -- do we order tests for people with suspected H pylori infection and then treat them once the bacteria has been confirmed, or do we treat them first, on the assumption that they are Helicobacter-positive. However, many doctors still want to test patients for virtually any gastric condition before treating them with PPIs, when perhaps the "treat-first" mode of practice should apply. "In our population we found that less than 2 percent had ulcers, and in the entire group, less than 1 percent had gastric or duodenal erosions, so ulcer disease is not a big cause of dyspepsia in gastroenterolgy in community practice." In this study, he said they would have only helped the 1.7 percent who had ulcers, and even then, the presence of H pylori had not been confirmed. "PPIs are a great class of drugs and their similarities are much greater than any differences. I would challenge anybody to say that the difference between one or two days is clinically significant. It might be statistically significant." "When a company claims that a sustained resolution with one drug is a mean of eight days versus seven days with another drug, that means that half [of patients] took more than eight days [to resolve] and half took less than eight days [to resolve], so we have to ask whether that is clinically significant." "My own bias is that patients come complaining of symptoms, and how the severity of these symptoms affects their work and their quality of life [must be considered]," Dr. Puera said. "This is the same whether somebody has erosive esophagitis or non-erosive reflux. Patients are not disabled because of the erosions in their esophagus - they are disabled because of symptoms."
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