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GENERAL PRACTICE:
James N R Bashford, Jeff Norwood, and Stephen R Chapman
Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice Research Database
BMJ 1998; 317: 452-456 [Abstract] [Full text]
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[Read Rapid Response] Frequency of nonulcer dyspepsia increases with the prescription of ulcer healing drugs
Ian Ross   (21 August 1998)

Frequency of nonulcer dyspepsia increases with the prescription of ulcer healing drugs 21 August 1998
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Ian Ross

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Re: Frequency of nonulcer dyspepsia increases with the prescription of ulcer healing drugs

Bashford et al. Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practive Research Database. BMJ 1998;317:452-6. (15 August.).

Bashford et al report a 10 fold rise in prescriptions for proton pump inhibitors (PPI) between 1991 and 1995, substantially due to increased unlicensed use for non-ulcer dyspepsia 1. Diagnosis of non-ulcer dyspepsia will be promoted by the frequent use of ulcer healing drugs (UHD) prior to referral for gastroscopy, because these drugs reduce diagnostic yield 2.

We audited 270 dyspeptic patients referred for gastroscopy to determine the ideal time to cease UHD before investigation. Fifty-seven-percent of patients had taken UHD in the 3 months prior to gastroscopy. Half of those treated received PPI. In a case control study comparing UHD treated patients with those who had not taken UHD within the 3 month period, treated subjects had a significantly reduced occurrence of mucosal inflammation at gastroscopy, e.g. oesophagitis and peptic ulcer disease. The odds ratio (OR) of not having mucosal inflammation when UHD were used within 2 weeks of gastroscopy was 3.1, (95% confidence interval (CI) 1.3 to 7.1, P < 0.01). The OR when UHD were consumed between 2 to 4 weeks prior to gastroscopy was 2.0, (95% CI 1.0 to 3.9, P < 0.04). UHD ceased more than 4 weeks before the test did not reduce diagnostic yield. Patients using UHD within 1 month of endoscopy were less likely to be positive for Helicobacter pylori on a CLOtestÔ.

In a telephone survey of 31 endoscopy units performed in July 1997, 14 (45%) gave no advice about discontinuing UHD before gastroscopy, and only 1 recommended cessation a month before the procedure.

In summary, UHD used up to 1 month before a gastroscopy reduce both diagnostic yield, and CLOtest positivity 3. Many endoscopy units do not advise patients to discontinue their UHD. This must exaggerate diagnosis of non-ulcer dyspepsia and will result in repeat prescriptions for patients who might have had a curable problem like a duodenal ulcer.

1 Bashford JNR, Norwood J, Chapman SR. Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice Research Database. BMJ 1998;317:452-6. (15 August.)

2 Mitchell RMS, Tham TCK, Collins JSA, Watson RGP. Differences in diagnostic yield of upper gastrointestinal endoscopy in dyspeptic patients on proton pump inhibitors and H2 receptor antagonists. Gut Supplement No 1 1997;40: A60.

3 Dickey W, Kenny BD, McConnell JB. Efffect of proton pump inhibitors on the detection of Helicobacter pylori in gastric biopsies. Aliment Pharmacol Ther 1996;10: 289-93.

Yours faithfully,

Dr Ian Ross F.R.C.P. Consultant Physician & Gastroenterologist The Newark Hospital Boundary Road Newark Nottinghamshire NG24 4DE