1. The Alosa Foundation
Balanced data about medications
www.RxFacts.orgBalanced data about medications
Managingdyspepsia:
neutralizingthehype
• gastroesophagealrefluxdisease(GERD)
• pepticulcerdisease(PUD)
• non-ulcerdyspepsia(NUD,orfunctionaldyspepsia)
In the patient with acid-related symptoms:
■■ look for precipitating meds and “red flag” signs or
symptoms.
■■ exclude serious non-GI causes.
■■ dealing with H. Pylori -- test patients who have:
• a history of ulcers, or
• age under 55 with new onset symptoms and without
obvious GERD.
• If positive, treat with “triple therapy” for 10-14 days.
■■ Lifestyle interventions can be useful in controlling
symptoms.
■■ Prescribe a medication if symptoms persist:
• Proton pump inhibitors (PPIs) are very effective, but may
not be necessary in all patients.
• Alternatives include H2 and antacids blockers.
2. 2
Initial assessment1-5
1. Look for precipitating medications, including aspirin, NSAIDs, anticholinergic drugs,
corticosteroids, theophylline, dopaminergic agents, oral bisphosphonates, and
calcium channel blockers.6
2. Exclude serious non-GI causes of dyspepsia, such as:
• coronary artery disease • aortic dissection
• pericarditis • pulmonary embolism
3. Look for “red flag” signs or symptoms – alarm features that might suggest cancer,
stricture or severe ulceration. If present, refer for endoscopy:
• recurrent vomiting • hematemesis • dysphagia
• GI bleeding • abdominal mass • anorexia
• early satiety • anemia • change in bowel habits
• odynophagia • hepatomegaly • unexplained weight loss
• lymphadenopathy • previous GI malignancy or ulcer
An approach to the patient with non-GERD dyspepsia5
Dyspepsia
Age > 55 or “red flags” Age ≤ 55 No “red flags”
Consider
Endoscopy
Figure reproduced with permission from:Talley NJ, Vakil N. Guidelines for
the management of dyspepsia. Am J Gastroenterol. Oct 2005;100(10):2324-2337.
H. Pylori prevalence
< 10%
H. Pylori prevalence
≥ 10%
PPI trial Test and treat
for H. pylori
Consider
Endoscopy
Consider
Endoscopy
Test and treat
for H. pylori PPI trial
Symptoms
persist
Symptoms
persist
Symptoms
persist
Symptoms
persist
3. 3
Non-prescription therapies often work well
• avoid acidic foods or those that precipitate symptoms (e.g., citrus, onions, tomatoes);
• avoid products that increase acid production or can damage mucosal defenses (NSAIDs,
alcohol, tobacco, caffeine).
H. pylori testing1,3,5
Evaluate patients with:
• active gastric or duodenal ulcer;
• history of gastric or duodenal ulcer not yet treated for H. pylori infection;
• new-onset dyspepsia in adults ≤ 55 years without obvious GERD and without red flag
signs or symptoms, in populations with high ulcer or H. pylori prevalence (e.g., immigrant
populations);
• patients who do not respond to treatment.
How to test:
For most patients:
• urea breath test and stool antigen test are accurate non-invasive diagnostic tools, but are
cumbersome to obtain in routine practice.
• serum antibody testing has lower sensitivity and specificity, but it is commonly ordered
because of its convenience.
If the patient undergoes endoscopy, a biopsy is the most accurate test.
If test is positive for H. Pylori, treat with triple therapy for 10-14 days:
• PPI, standard dose twice daily, and
• amoxicillin* 1000 mg twice daily, and
• clarithromycin 500 mg twice daily.
*Metronidazole (500 mg twice daily) should be substituted for amoxicillin in patients with
penicillin allergy.
Single-prescription triple therapy (Prevpac) is convenient, but more expensive than individual
medications.
For Patients With Acid-Peptic Disease:
4. 4
For patients with GERD:2,4,5,7
:
Lifestyle interventionsEndoscopy
No (majority of patients)Yes
Short course of
PPI, or as-needed
H2 blocker or
antacid
Heartburn and/or acid regurgitation as the predominant
or frequent ( 1 episode per week) presenting complaint
“red flag” features?
(a minority of patients)
Endoscopy-
negative reflux
disease
Esophagitis
For further management, see figure below,
“If additional treatment is required”
High dose PPI
for 4-8 weeks
if symptoms persist
Manage other abnormal endoscopic findings based on the diagnosis.
Lifestyle modification can greatly help reduce reflux:
• eliminate substances that reduce tone in the lower esophageal sphincter (caffeine, alcohol,
tobacco, mint, chocolate, fatty or fried foods);
• avoid large meals right before bedtime;
• elevate the head of the bed;
• avoid tight clothing that constricts the abdomen;
• do not recline within 2-3 hours after a meal;
• lose weight if overweight.
5. 5
Although PPIs are often taken on an as-needed basis, they do not work well in this way because
they can require more than 24 hours to reduce acid production and achieve symptom relief. By
contrast, antacids are effective within minutes and H2 blockers work within an hour.
Avoid “as-needed PPI’’
Time required for symptom relief
0
Hours
0 5 10 15 20 25 30
PPIs
H2 blockers
Antacids
30-60 minutes
5-20 minutes
24 hours
PPIs cause more adverse effects than H2 blockers8
...
• headache
• diarrhea
• abdominal pain
...and PPIs carry a risk of more serious adverse effects:
• clostridium difficile infection
• fractures
• interstitial nephritis
• pneumonia
• potentially reduced efficacy of clopidogrel
• rebound acid hyper-secretion when PPI stopped.
6. 6
Who really needs a PPI?
Patient taking PPI
e.g. omeprazole
20mg twice daily
Reduce the dose
by half for 2 weeks
e.g. omeprazole
20mg once daily
Stop the PPI
If needed, use:
• a generic or
OTC H2 blocker
such as ranitidine
(Zantac)
• an antacid
Long term
Slowly reduce the
dose of H2 blocker
or antacid to the
lowest amount
needed to control
symptoms
Only a few conditions require long-term use of PPIs:
• GERD with esophagitis, ongoing symptoms, or complications such as Barrett’s esophagus
• recurrent Peptic Ulcer Disease
• Zollinger-Ellison Syndrome
For everybody else:
• Re-evaluate after 4-8 weeks
• Use step-down therapy
• Taper PPIs and educate about using H2 blockers and/or antacids.
Plan on tapering and then discontinuing PPIs in patients with:
• GERD without esophagitis if symptom-free after 4 weeks of therapy
• Peptic Ulcer Disease if symptom-free after 4-8 weeks of therapy and H. pylori eradication
• Non-Ulcer Dyspepsia if symptom-free after 4-8 weeks of therapy
This tapering regimen, including the use of as-needed H2 blockers and antacids, can control
rebound symptoms and provide the best chance of successfully stopping PPIs.
7. 7
If additional treatment is required1-5
…
GERD
(with esophagitis)
GERD
(without esophagitis)
• high dose PPI for 4-8
weeks (as per
algorithm above), then:
(i) long-term daily PPI
therapy titrated down
to the lowest effective
dose based on
symptom control, or
(ii) long-term daily PPI at
maintenance doses
for patients with
erosive disease
Peptic Ulcer Disease Non-Ulcer Dyspepsia
If additional treatment is required…1-5
• short course of PPI, or
as-needed H2 blocker
or antacid (as per
algorithm above), then:
(i) if symptoms resolve,
taper down dose of PPI.
Change to H2 blocker or
antacid and taper down
to lowest effective daily
or prn dose, or
(ii) if symptoms persist,
standard dose PPI once
or twice daily
• stop smoking and avoid
excessive alcohol
• discontinue aspirin/
NSAIDS if possible; if
these agents need to be
continued, add a PPI or
misoprostol
• treat bleeding or other
complications
• test and treat for H. pylori
• PPI for 4-8 weeks
• confirm eradication of
H. pylori
• if H. pylori still present,
make a second attempt
at eradication
if symptoms persist or a
second attempt at H. pylori
eradication fails,
consider referral
• PPI or H2 blocker for
4-8 weeks
• consider testing and
treating for H. pylori
• if no response, consider
prokinetic agent,
antidepressant therapy,
cognitive behavioral
therapy, or hypnotherapy
if symptoms persist,
consider specialist referral
If symptoms persist, consider specialist referral for:
• endoscopy
• manometry
• pH monitoring
• surgery
Choosing among medications
The different PPIs have similar efficacy, but big differences in economic burden.9-13
The costs of
a 30-day supply of commonly used daily doses of acid-neutralizing/suppressive medications are
provided in the figure on the following page.
