Fortnightly review: Treatment of gastro-oesophageal reflux disease in adults

Background/Aim: Proton pump inhibitor (PPI) prescribing is costly. The volume of PPI prescription is also increasing, despite little evidence that would justify the increase. General practitioners (GPs) are largely responsible for PPI prescribing, yet knowledge of their views concerning PPIs which might explain the apparent anomaly of prescribing costly drugs without justification is lacking. The aim of this study is therefore to investigate how GPs make decisions about PPI prescribing. Method: Qualitative study design using focus groups of 34 GPs and 15 training GPs analysed according to grounded theory principles and use of constant comparative analysis. Results:The participants showed agreement about the clinical factors potentially relevant to PPI prescribing such as age of presentation and endoscopy, issues of Helicobacter pylori eradication and issues around malignancy. There was considerable controversy, however, as to how to apply those factors in real clinical consultations. GPs in training and academic GPs tended to be more conservative; service-based GPs more pragmatic. There was agreement about the need to review long-term PPI medication, but controversy about whether the conventional ‘step-up step-down’ approach was realistic in practice. Good agreement was apparent about the effectiveness, the cost implications, and some of the ethical issues surrounding PPIs, but considerable controversy as to how far such factors should influence prescribing of PPIs. Conclusion:The GPs showed good understanding and knowledge of the issues surrounding PPI prescribing. There was considerable controversy as to how such knowledge should be translated into practice.

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“…Cost-effectiveness of the approach used may be determined by the severity of GORD in the patients studied [28]. …”

Section: Discussionmentioning

confidence: 99%

Use of Proton Pump Inhibitors: An Exploration of the Attitudes, Knowledge and Perceptions of General Practitioners

Raghunath¹,

Hungin²,

Cornford³

et al. 2005

Digestion

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“…Once again, different management strategies can be applied, namely intermittent or on-demand drug therapy, or maintenance therapy [19,40]. The first is suitable for patients with mild or moderate symptoms and infrequent relapses.…”

Section: Discussionmentioning

confidence: 99%

Endoscopy-negative reflux disease

Galmiche

Varannes

2001

Curr Gastroenterol Rep

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Endoscopy-negative reflux disease (ENRD) is more prevalent than reflux esophagitis, especially in a primary care setting. Acid-sensitive esophagus (ie, reflux-related symptoms with normal acid exposure at 24-hour pH monitoring) is part of the gastroesophageal reflux disease spectrum. ENRD is not a mild disease (symptoms return frequently and have an impact on quality of life), but it rarely progresses to the erosive stage. In patients with atypical or extra-esophageal manifestations, pH monitoring remains useful, and symptom analysis (symptom index or symptom-associated probability) is of pivotal importance. A proton pump inhibitor (PPI) test may represent a cost-effective alternative to 24-hour pH monitoring. However, well-designed validation studies are necessary to assess the diagnostic value of PPI tests and improve specificity without reducing sensitivity. Management of ENRD is based on the same principles as that of reflux esophagitis. Restoration of quality of life is the major goal. Proton pump inhibitors are not more (and are sometimes even less) effective in non-erosive reflux disease than in reflux esophagitis. Different long-term strategies (continuous maintenance, intermittent or on-demand therapy) are available, depending on the needs of the patient. Antireflux surgery may be indicated in carefully selected patients. In the future, pharmacologic approaches targeted to transient lower esophageal sphincter relaxation or visceral perception should be developed.

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“…Grundsätzlich folgen Diagnostik und Therapie von GERD beim älteren Patienten dem gleichen Prinzip wie beim jüngeren Patient. Wegen der erhöhten Inzidenz von Komplikationen und atypischer Symptomatik sollte die Endoskopie eher erfolgen als beim jüngeren Patienten [7,11]. Die Therapieziele sind altersunabhän-gig, jedoch benötigt der ältere Patient eine agressivere und längere medikamentöse Therapie und höhere Dosen vergleichbarer Medikamente zur Heilung der Oesophagitis wie auch zur Komplikationsprophylaxe [4].…”

Section: Diskussionunclassified

“…Behandlungsziel ist die Unterbindung des pathologischen Refluxes durch Wiederherstellung der physiologischen Antirefluxbarriere, die Eliminierung sämtlicher daraus resultierenden Symptome sowie eine Steigerung der Lebensqualität. Die Indikation zur laparoskopischen Antirefluxchirurgie (laparoscopic antireflux surgery = LARS) ist auch beim ¾lteren klar definiert: Patienten mit persistierenden oder rezidvierenden Symptomen unter adäquater medikamentöser Therapie und mit nachgewiesenem Funktionsdefekt am unteren Oesophagussphincter [7,11]. Zusätzliche Kriterien stellen die reduzierte Lebensqualität und der Allgemeinzustand der Patienten dar.…”

unclassified