A. S. Raghunath

Prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease: systematic review

Abstract Objectives: To ascertain the prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease and its association with the disease. Design: Systematic review of studies reporting the prevalence of H pylori in patients with and without gastro-oesophageal reflux disease. Data sources: Four electronic databases, searched to November 2001, experts, pharmaceutical companies, and journals. Main outcome measure: Odds ratio for prevalence of H pylori in patients with gastro-oesophageal reflux disease. Results: 20 studies were included. The pooled estimate of the odds ratio for prevalence of H pylori was 0.60 (95% confidence interval 0.47 to 0.78), indicating a lower prevalence in patients with gastro-oesophageal reflux disease. Substantial heterogeneity was observed between studies. Location seemed to be an important factor, with a much lower prevalence of H pylori in patients with gastro-oesophageal reflux disease in studies from the Far East, despite a higher overall prevalence of infection than western Europe and North America. Year of study was not a source of heterogeneity. Conclusion: The prevalence of H pylori infection was significantly lower in patients with than without gastro-oesophageal reflux, with geographical location being a strong contributor to the heterogeneity between studies. Patients from the Far East with reflux disease had a lower prevalence of H pylori infection than patients from western Europe and North America, despite a higher prevalence in the general population. What is already known on this topic The relation between H pylori infection and gastro-oesophageal reflux disease is controversial Studies on the prevalence of H pylori in patients with gastro-oesophageal reflux disease have given conflicting results Recent guidelines recommend eradication of H pylori in patients requiring long term proton pump inhibitors, essentially for reflux disease What this study adds Despite heterogeneity between studies, the prevalence of H pylori was significantly lower in patients with than without gastro-oesophageal reflux disease Further well designed studies are required to establish the clinical relevance of the findings, particularly in eradication therapy

Review article: the long-term use of proton-pump inhibitors

More than 15 years after the launch of omeprazole in 1988, proton‐pump inhibitors remain central to the management of acid‐suppression disorders and are unchallenged with regard to their efficacy and popularity among doctors and patients. They are considered safe despite early concerns about the possibility of an association with cancer and gastric atrophy; current concerns about long‐term proton‐pump inhibitor therapy are centred mainly on a possible association with fundic gland polyps and between Helicobacter pylori and gastric atrophic changes. Long‐term proton‐pump inhibitor usage accounts for the majority of the total proton‐pump inhibitor usage. Long‐term usage is difficult to define and most patients take proton‐pump inhibitors non‐continuously. Data indicate that a substantial proportion of long‐term users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment. Overall, on‐demand therapy is more cost‐effective than continuous therapy and should be considered wherever possible.

Systematic review : the effect of helicobacter pylori and its eradication on gastro-oesophageal reflux disease in patients with duodenal ulcers or reflux oesophagitis.

Background : The effect of Helicobacter pylori in provoking or protecting against gastro‐oesophageal reflux disease is unclear and studies have given conflicting results. Recent guidelines recommend H. pylori eradication in patients on long‐term proton pump inhibitors.

Systematic review: frequency and reasons for consultation for gastro-oesophageal reflux disease and dyspepsia

Background  Upper gastrointestinal symptoms impose a substantial illness burden and management costs. Understanding perceptions and reasons for seeking healthcare is a prerequisite for meeting patients’ needs effectively.

Systematic Review: Patterns of Proton Pump Inhibitor Use and Adherence in Gastroesophageal Reflux Disease

BACKGROUND & AIMS Variation in how proton pump inhibitors (PPIs) are taken likely influences their clinical effectiveness, and must be considered when estimating PPI failure rates. This review aimed to systematically investigate the literature on patterns of PPI use in patients with gastroesophageal reflux disease (GERD). METHODS PubMed and Embase were searched (1989-May 2010) to identify observational studies providing information on patterns of PPI use in patients with GERD. RESULTS Of 902 studies identified, 13 met prespecified selection criteria. Across 2 database studies, 53.8%-67.7% of patients with GERD had a medication possession ratio (MPR) of >0.80. Across 2 more database studies, the mean MPR for the study population was 0.68 to 0.84. Across 3 surveys, 70%-84% of patients reported daily PPI use. In 2 surveys, the presence and severity of reflux symptoms increased PPI adherence, as did Barretts esophagus in another 2 studies. Across 3 surveys, 11%-22.2% of patients reported twice daily PPI use, and across 6 studies 11.0%-44.8% of patients took GERD medication in addition to a PPI. CONCLUSIONS The results of this systematic review suggest that the majority of patients with GERD are relatively adherent to their PPI, although substantially different estimates were obtained using MPR data compared with surveys. Severe symptoms and the presence of Barretts esophagus may increase PPI adherence, and other GERD medication is frequently taken in addition to a PPI. Limitations of studies in this area include inferring adherence from indirect MPR data, and recall bias associated with patient surveys.

Symptoms in patients on long-term proton pump inhibitors : prevalence and predictors.

Background  Symptom control in primary care patients on long‐term proton pump inhibitor (PPI) treatment is poorly understood.

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

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.

Managing Gastro-Oesophageal Reflux Disease in the Older Patient

Gastro-oesophageal reflux disease (GORD) in older patients presents particular problems for the clinician. Older patients may present with complications rather than with symptoms, which may be less marked than in younger patients. Extraoesophageal symptoms are also more common in this group, and this may lead to confusion over the exact diagnosis. The increased likelihood of co-pathologies and concomitant medication complicate diagnosis and management further. GORD tends to be more severe for any level of symptom severity in the older patient. Erosive oesophagitis is more common among older people with GORD, meaning that this group is more likely to require aggressive therapy for both symptom relief and oesophagitis healing – full or high doses of acid suppression therapy may be necessary.

Helicobacter pylori eradication in long‐term proton pump inhibitor users in primary care: a randomized‐controlled trial

Background  Two‐thirds of proton pump inhibitor prescribing in the UK is for long‐term therapy.

Helicobacter pylori eradication in long-term proton pump inhibitor users is highly cost-effective: economic analysis of the HELPUP trial

Background  Proton pump inhibitor (PPI) use is costly and about two‐thirds of prescribing is long‐term. Although 20–50% of patients may be infected with Helicobacter pylori, eradication is not normal clinical practice.