Pål Kristensen

Cimetidine Responders in Non-Ulcer Dyspepsia

The effect of cimetidine and placebo was examined in 123 patients with non-ulcer dyspepsia (NUD) by means of a 12-day multi-crossover model with 5 regular interchanges between cimetidine and placebo. The evaluation of effect in individual patients was based on the number of times cimetidine was associated with less symptoms than the preceding or following placebo period. If cimetidine had no effect, the probability of being defined as a cimetidine responder was 25%. In general, cimetidine was associated with less symptoms than placebo (p less than 0.0001). Forty patients were identified as cimetidine responders (R) and the remaining patients were termed non-responders (NR). Symptoms compatible with gastroesophageal reflux were significantly more frequent in R than in NR, whereas the opposite was true for symptoms of the irritable colon syndrome. The ability of symptoms selected by stepwise logistic regression to predict response to cimetidine showed at best a sensitivity of 75% and a specificity of about 65%. No differences were found between R and NR with regard to acid secretion, endoscopic and histologic findings, or the result of an acid perfusion test. The present study supports the existence of a subgroup of cimetidine responders among patients with NUD characterized by symptoms suggestive of gastroesophageal reflux disease in the absence of confirmatory objective evidence.

The effect of cimetidine in non-ulcer dyspepsia: experience with a multi-cross-over model

The symptomatic effect of cimetidine was examined in 27 patients with non-ulcer dyspepsia (NUD) by means of a multi-cross-over model (MCO model) for testing the symptomatic effect of drugs in individual patients. None of the patients showed an ulcer at the time, but 20 patients had evidence of previous peptic ulcer disease. The variant of the MCO model used included six treatment periods and three regular interchanges between cimetidine and placebo. Treatment periods lasted 2 or 4 days. The individual results were evaluated on the basis of the number of times (X score) cimetidine was associated with less symptoms than the preceding or following placebo. In general, cimetidine was associated with significantly (p less than 0.02) less symptoms than placebo. The X-score distribution was therefore skew in favour of high scores. Five patients showed the maximal X score of 5. The chance of getting an X score of 5 when cimetidine is not better than placebo is about 9%. Accordingly, the risk of being wrong when defining these five patients as cimetidine responders is 9%. The present study confirms that the MCO model may identify individual cimetidine responders among patients with NUD.

The intensity and variability of symptoms in dyspepsia

During the waiting time for upper gastrointestinal endoscopy 165 patients with dyspepsia completed a questionnaire and a diary for daily measurements of the symptoms pain, heartburn, and global complaints. 23 patients (14%) had peptic ulcer disease (PUD), 18 oesophagitis (11%), and the rest were labelled nonulcer dyspepsia (NUD). NUD was further subdivided into ulcer-like, reflux-like, dysmotility, and essential NUD by means of predefined symptom profiles. 39 (24%) patients were on H2 receptor antagonist treatment. In general, the intensity of the daily symptoms was rather low, and except for a higher rating of heartburn in oesophagitis, there were no significant differences between PUD, oesophagitis, and NUD--treated or untreated. NUD patients with reflux-like dyspepsia had significantly more heartburn than the group with essential NUD; otherwise there were no differences between the subgroups of NUD. The individual daily ratings for abdominal pain, heartburn, and global symptoms varied by an average standard deviation of 64%, 97% and 47% of the mean values, respectively, and were independent of treatment or diagnoses. There was an approximately 40% probability that two successive days had different levels of symptoms. Only 10% of the patients showed stable symptoms, and the patients were completely symptom-free for 20% of the observation period. Symptoms in dyspepsia patients disclosed low intensity and high variability in this study. Such factors may be important sources of bias in clinical trials.

Cimetidine On-Demand in Dyspepsia Experience with Randomized Controlled Single-Subject Trials

Double-blind randomized controlled trials in single subjects (N of 1 RCTs) have demonstrated a beneficial symptomatic effect of cimetidine in reflux- or ulcer-like non-ulcer dyspepsia (NUD). However, spontaneous fluctuations in symptoms reduce the validity of such trials when performed as continuous trials with fixed dosages. This study was carried out to identify individual responders to cimetidine in NUD, peptic ulcer disease, and oesophagitis and to confirm the beneficial average effect of cimetidine in these clinical entities. We evaluated N of 1 multi-crossover trial designs, which compare the effects of single doses of cimetidine and placebo taken on-demand for symptomatic relief. Each trial consisted of six cimetidine (400 mg or 800 mg) and six placebo tablets randomized in successive pairs. The symptomatic effect of each tablet was measured 1/2-6 h after the intake. Outcomes were assessed by individual p values and confidence intervals. A minimal clinically important difference was defined, to assess the clinical significance as demonstrated by the confidence intervals. Thirteen of 25 patients (52%) with reflux- and ulcer-like NUD obtained individual p values below 0.20. Similarly, 7 of 9 patients (78%) with oesophagitis and 6 of 12 patients (50%) with peptic ulcer obtained such p values. On the basis of the 80% confidence intervals the corresponding numbers of subjects with clinically significant effect were six (NUD), three, and three. The combined data showed a significantly better effect of cimetidine than of placebo (p less than 0.0001) in each of the three diagnostic groups studied. Cimetidine taken on-demand may have a rapid symptom-relieving effect in dyspepsia.(ABSTRACT TRUNCATED AT 250 WORDS)

The Natural Course of Peptic Ulcer Disease and its Predictors

BACKGROUND Little is known about todays natural course of peptic ulcer disease (PUD). METHODS A follow-up study based on a structured telephone interview was attempted in 728 patients with an endoscopic diagnosis of peptic ulcer in 1980-84. RESULTS Seven patients (1%) died because of PUD during the 8- to 10-year follow-up period. Of the 441 interviewed patients 15.2% had experienced no further clinical manifestations of PUD, 10.9% had had bleeding and 0.7% perforation, and 17.5% had been operated on. The operated patients reported fewer symptoms (p < 0.01) during the last 2 weeks before the interview than those not operated on. On an average the unoperated patients had had symptoms and had used histamine-2-receptor antagonists (H2RA) 12 and 10 weeks per year, respectively. Long-term treatment with H2RA was reported by 18%. More than one-third (36%) of the unoperated patients stated that the symptoms had had a significant negative impact on their lives. Age at onset of disease and index ulcer, family history, use of anti-inflammatory drugs and alcohol, bleeding, and another chronic disease were found to be significant predictors of the course. CONCLUSION In more than one-third of the patients with PUD the course is still burdened with many symptoms and complications.

The Symptomatic Effect of 1-Day Treatment Periods with Cimetidine in Dyspepsia Combined Results from Randomized, Controlled, Single-Subject Trials

Before endoscopy a double-blind, randomized, controlled, single-subject trial comparing the symptomatic effect of 1-day treatment periods with cimetidine and placebo was conducted in patients with dyspepsia. Results from 339 patients were analysed. The trial lasted 12 days and consisted of 6 treatment days with 400 mg cimetidine three times daily and 6 days with placebo three times daily. The order of the treatments was randomized within six pairs, and a randomization test based on daily measures of global symptoms provided individual p values. Aggregation of the measures from all subjects showed that cimetidine alleviated the symptoms significantly better than placebo in peptic ulcer disease (PUD) (p less than 0.0001), oesophagitis (p less than 0.001), and non-ulcer dyspepsia (NUD) (p less than 0.0001). Twenty-seven per cent of the patients with PUD, 26% of those with oesophagitis, and 12% of the patients with NUD obtained individual p values of less than 0.10 and were defined as responders. The best predictors of the response to cimetidine in NUD were age above 40 years, heartburn or acid regurgitations being the worst symptom, and night pains relieved by food, milk, or antacids. In conclusion, the applied single-subject trial confirmed the overall symptomatic effect of cimetidine in dyspepsia and identified individual responders among patients with NUD with a clinically reasonable profile. The low proportion of responders among patients with PUD or oesophagitis suggests that the model has a low sensitivity for identification of individual responders and that the single-subject trial design in dyspepsia needs further refinement.

On-demand therapy in gastroesophageal reflux disease: a comparison of the early effects of single doses of fast-dissolving famotidine wafers and ranitidine tablets

In this double-masked, double-dummy, randomized, single crossover study, we compared single doses of a fast-dissolving wafer formulation of famotidine with a conventional tablet formulation of ranitidine in patients with gastroesophageal reflux disease (GERD). Patient preference time until symptomatic relief, and predictive characteristics of early responders were assessed. Eligible patients had a clinical diagnosis of GERD and symptoms of GERD of sufficient severity to require relief. The study treatment was one dose of famotidine (20-mg wafer) and one dose of ranitidine (150-mg tablet), which were given in a randomized order and taken as needed. The patients were instructed to measure the symptomatic effects on a seven-point categorical scale (1 = worse to 7 = free of symptoms) at 15, 30, 45, 60, 120, and 180 minutes. After the clinical phase of the trial, the patients indicated their global assessment of efficacy and their preference for the wafer or the tablet. Of the 829 patients who completed the study, significantly more preferred the wafer to the tablet. While there was no significant difference in the global assessment of efficacy, the famotidine wafer provided significantly better relief than the ranitidine tablet during the first hour after dosing. However, at 120 and 180 minutes, the degree of relief was similar for the two drugs. The time until a clinically significant effect was also similar for the two drugs, and approximately one half of the patients experienced such improvement within 3 hours. Multivariate analyses disclosed no predictive characteristics of early symptomatic effect.

Abdominal complaints in general practice.

Objective – The study evaluates the prevalence and diagnoses of abdominal complaints in general practice, and compares characteristics and symptoms of patients with functional gastrointestinal disorders (FGIDs) and organic diseases. Design – A cross-sectional study. Setting – Nine centres with 26 participating general practitioners (GPs) in Norway. Subjects – 3097 out of 3369 consecutive adult patients answered a questionnaire regarding abdominal complaints within the last 3 months. Those who consulted for the complaints were eligible for this study. Main outcome measures – The GPs’ diagnoses and patients’ characteristics were reported in questionnaires. Results – 460 out of 1499 patients with abdominal complaints consulted for these complaints; 392 were included in this study. The GPs diagnosed a FGID in 167 (42.6%) patients, organic disease in 145 (37.0%), and made no diagnosis in 80 (20.4%). Stress-related symptoms were a statistically significant predictor of a FGID (OR 1.95) and weight loss predicted in addition organic disease (OR 2.7) in 128 patients with a verified diagnosis. Conclusion – Abdominal complaints are a common problem in general practice. The distinction between FGID, which accounted for half of the diagnoses, and organic disease was difficult. The only significant predictor for FGID was stress-related symptoms.

Abdominal complaints in general practice: diagnoses and characteristics of patients.

Objective – The study evaluates the prevalence and diagnoses of abdominal complaints in general practice, and compares characteristics and symptoms of patients with functional gastrointestinal disorders (FGIDs) and organic diseases.Design – A cross-sectional study.Setting – Nine centres with 26 participating general practitioners (GPs) in Norway.Subjects – 3097 out of 3369 consecutive adult patients answered a questionnaire regarding abdominal complaints within the last 3 months. Those who consulted for the complaints were eligible for this study.Main outcome measures – The GPs’ diagnoses and patients’ characteristics were reported in questionnaires.Results – 460 out of 1499 patients with abdominal complaints consulted for these complaints; 392 were included in this study. The GPs diagnosed a FGID in 167 (42.6%) patients, organic disease in 145 (37.0%), and made no diagnosis in 80 (20.4%). Stress-related symptoms were a statistically significant predictor of a FGID (OR 1.95) and weight loss predicted in a...

Clinical significance of upper abdominal symptoms

Upper abdominal symptoms are frequent in the healthy population. The clinical significance of upper abdominal symptoms appears to be slight when evaluated singly but more satisfactory when taken together. There is an urgent need for an improved data base of information with regard to the relationship between upper abdominal symptoms and disease.