Prescribing of proton-pump inhibitors: auditing the management and reasons for prescribing in Danish general practice.

BACKGROUND: Prescribing of proton-pump inhibitors has substantially increased. Information from clinical settings is warranted to gain insight into reasons for prescribing. AIM: To investigate Danish General Practitioners' management and reasons for prescribing of proton-pump inhibitors and to identify areas for quality improvement. METHODS: All general practitioners in the Region of Southern Denmark and their staff were invited to participate in a 4-week audit on all contacts with patients prescribed proton-pump inhibitors. For each contact, patient characteristics, treatment duration, dose and causes of treatment, previous gastroscopy, Helicobacter pylori test, and decision about future treatment were recorded. RESULTS: A total of 51 general practitioners and 47 staff members sampled information about 1101 and 741 patients, respectively. Proton-pump inhibitors had been taken for more than 2 years in 58% of the cases, and 64% of the patients used it daily. Treatment was based on an appropriate reason in three of the four patients, most often due to acid-related symptoms. No gastroscopy had been performed in 46% of the patients, and one of four had had a consultation with the general practitioner regarding proton-pump inhibitor within the last year. CONCLUSION: Most patients treated with proton-pump inhibitors are treated daily, on a long-term basis, and due to symptoms. Few consultations led to alterations in treatment, and only 25% of patients had a consultation regarding proton-pump inhibitor treatment with their general practitioner within the last year. Substantial variability between general practitioners with regard to management was detected.

Randomized clinical trial: the impact of gastrointestinal risk factor screening and prophylactic proton pump inhibitor therapy in patients receiving dual antiplatelet therapy.

OBJECTIVE: Dual antiplatelet therapy reduces the risk of ischemic complications after acute coronary syndrome, but increases the risk of bleeding including upper gastrointestinal bleeding (UGIB).The aim of this study was to examine the effect of screening for risk of UGIB and prophylactic proton pump inhibitor (PPI) treatment in dual-antiplatelet-treated patients at risk of UGIB and to assess the significance of dual antiplatelet therapy compliance for cardiovascular events. PATIENTS AND METHODS: In a register-based randomized-controlled trial, 2009 patients were included at the time of first percutaneous coronary intervention and randomized to either screening or control. Screened high-risk patients were prescribed pantoprazole 40 mg during the 1-year after percutaneous coronary intervention. RESULTS: The incidence of UGIB was 0.8 versus 1.3% in screened patients and controls, respectively (P=0.381).Significantly fewer screened patients (5.4%) than controls (8.0%) underwent upper gastrointestinal endoscopy (P=0.026). Screened patients (2.9%) had significantly fewer events of unstable angina pectoris than controls (4.7%) (P=0.036) and a higher compliance to dual antiplatelet therapy (88.3 vs. 85.0%) (P=0.035), but no statistically difference was observed in the incidences of myocardial infarction and all-cause mortality (1.0 vs. 1.5%) (P=0.422). CONCLUSION: Screening for risk factors for UGIB and subsequent prophylactic PPI treatment did not significantly reduce the incidence of UGIB. Prescription of PPI was associated with a higher compliance with dual antiplatelet therapy and decreases the risk of recurrent cardiovascular events.

Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study.

BACKGROUND AND AIMS: The optimal timing of endoscopy in patients with peptic ulcer bleeding (PUB) remains unclear. The aim of this study was to examine the association between timing of endoscopy and mortality in PUB. METHODS: In a nationwide cohort study based on a database of consecutive patients admitted to the hospital with PUB in Denmark, patients were stratified according to the presence of hemodynamic instability at presentation and American Society of Anesthesiologists (ASA) score. Using descriptive statistics and logistic regression analyses, we identified optimal time frames for endoscopy and analyzed the association between timing of endoscopy and in-hospital mortality after adjusting for confounding factors. RESULTS: In total, 12,601 patients were included. We did not find any universal association between timing of endoscopy and mortality in hemodynamically stable patients with an ASA score of 1 to 2. In hemodynamically stable patients with an ASA score of 3 to 5, endoscopy 12 to 36 hours after admission to the hospital was associated with lower in-hospital mortality (OR, .48; 95% CI, .34-.67) compared with endoscopy outside this time frame. In patients with hemodynamic instability, endoscopy 6 to 24 hours after admission to the hospital was associated with lower in-hospital mortality (OR, .73; 95% CI, .54-.98) compared with endoscopy outside this time frame. CONCLUSIONS: Timing of endoscopy is associated with mortality in patients with PUB and an ASA score of 3 to 5 or hemodynamic instability. Our findings suggest that in these patients, a period of time to optimize resuscitation and manage comorbidities before endoscopy may improve outcome.

High prevalence of ulcer bleeding risk factors in dual antiplatelet-treated patients after percutaneous coronary intervention.

INTRODUCTION: Dual antiplatelet therapy is standard treatment following percutaneous coronary intervention (PCI) and stenting. However, such therapy increases the risk of upper gastrointestinal bleeding (UGIB). The risk factors of UGIB are well-documented and proton pump inhibitor (PPI) treatment reduces the risk. The aim was to describe the prevalence of risk factors of UGIB in dual antiplatelet-treated patients. METHODS: A questionnaire was used to assess the prevalence of risk factors of upper gastrointestinal bleeding among dual antiplatelet-treated first-time PCI patients in Western Denmark. The following characteristics were considered risk factors: increasing age (age 60-69 years and ≥ 70 years); dyspepsia; previous peptic ulcer; use of non-steroidal anti-inflammatory drugs (NSAIDs) (weekly or daily), corticosteroids, selective serotonin reuptake inhibitors (SSRIs) and anticoagulants. RESULTS: A total of 1,358 patients with a mean age of 64.1 years (range: 33-92 years) were included. The distribution of risk factors was as follows: dyspepsia: 681 patients (50.1%); previous ulcer: 110 (8.1%; 2.3% with bleeding); use of NSAIDs: 214 (15.8%); corticosteroids (2.9%), SSRIs (5.8%) and anticoagulants (6.3%). Defined high-risk patients: 886 (65.2%). PPI treatment prior to PCI was found in 248 (18.3%), of whom 86% were at high risk of UGIB. CONCLUSION: This study demonstrates a high prevalence of risk factors among PCI patients treated with dual antiplatelet therapy, many of whom were not in PPI treatment.

Prevalence of chronic rhinosinusitis in a population of patients with gastroesophageal reflux disease.

BACKGROUND: An increased coexistence of gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) has been reported in epidemiologic and register studies, and reflux has been shown more frequently in patients with CRS in studies using esophagus pH manometry compared to participants without CRS. A discussion is ongoing about whether there might be an association between these two diseases and, if so, whether the association is causal. OBJECTIVE: The purpose of this study was to clinically investigate the prevalence and symptom severity scores of CRS among patients with GERD. The results were compared with those of a randomly assigned control group from the general Danish population. METHOD: In this case-control study, 82 patients with GERD were examined for CRS using the European Position Paper on Rhinosinusitis and Nasal Polyps criteria, which combine patient history and anterior/posterior rhinoscopy results. Sinonasal-related quality of life was assessed by using the Sino-Nasal Outcome Test 22 (SNOT-22). These results were compared with those of a population-based control group examined for CRS in the same way. RESULTS: The prevalence of CRS among patients with GERD was 20.7% (95% confidence interval [CI], 12.0%-29.5%), significantly higher than the CRS prevalence of 8.5% (95% CI, 6.8%-10.2%) in the background population. Patients with GERD and CRS had an average SNOT-22 score of 43.8, whereas patients with CRS from the background population scored, on average, 28.1. Having GERD increased the mean SNOT-22 score in patients with CRS by 15.7 (95% CI, 6.5-24.9). CONCLUSION: The results of this study provide additional evidence of an association between GERD and CRS and indicate that GERD may play a role in the development of CRS. The results also show that sinonasal-related quality of life is decreased in patients with CRS who also suffer from GERD.

Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding.

BACKGROUND & AIMS: Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification. METHODS: We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk. RESULTS: There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%). CONCLUSIONS: A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.

Strategies for discontinuation of proton pump inhibitors: a systematic review.

PURPOSE: Proton pump inhibitors (PPIs) are considered to be overprescribed. Consensus on how to attempt discontinuation is, however, lacking. We therefore conducted a systematic review of clinical studies on discontinuation of PPIs. METHODS: Systematic review based on clinical studies investigating discontinuation strategies and discontinuation rates for users of antisecretory medication judged eligible for withdrawal. The databases Medline, Embase and Cochrane Library were searched to December 2013 using the terms antisecretory, anti-ulcer, PPI, acid suppressant, discontinuation, step-down, step down, cessation, tapering, withdrawal and withhold. Search terms were used either singularly or in combination. Papers written in English or Scandinavian were included. Concurrent hand searching was undertaken to pursue references of references. The website ClinicalTrials.gov was searched for unpublished results and ongoing studies. A total of 371 abstracts were scrutinized to determine relevancy. RESULTS: The thorough search resulted in six clinical studies on strategies for discontinuation of PPIs. All discontinuation regimens used in the studies differed, and several interventions have been tested in order to decrease use of PPIs. Discontinuations were reported across all studies ranging from 14% to 64% without deteriorating symptom control. Tapering seems to be a more effective discontinuation strategy than abrupt discontinuation. CONCLUSION: Discontinuation of PPIs is feasible in a clinical setting, and a substantial number of the patients treated without a clear indication can safely reduce or discontinue treatment. Tapering seems to be the most effective way of doing this.

Spironolactone use and the risk of upper gastrointestinal bleeding: a population-based case-control study.

AIMS: Recent studies have suggested an increased risk of upper gastrointestinal bleeding (UGB) in spironolactone users. The aim was to confirm the association, identify the risk factors and quantify the absolute risk. METHODS: A population based case-control study was conducted in the County of Funen, Denmark. Cases (n = 3652) were all subjects with a first discharge diagnosis of serious UGB during the period 1995 to 2006. Age- and gender-matched controls (10 for each case) (n = 36 502) were selected by risk set sampling. Data on all subjects' drug exposure and past medical history were retrieved from a prescription database and from the County's patient register. Confounders were controlled by conditional logistic regression. RESULTS: The adjusted odds ratio (OR) associating current use of spironolactone with UGB was 2.7 [95% confidence interval (CI) 2.2, 3.2]. The risk increased with higher doses of spironolactone (5.4; 3.4, 8.6) for 100-mg tablets. No trend was found with increasing cumulative dose. The strongest association was found among users aged 55-74 years (OR 13.1; 6.5, 26.3). Current use of loop diuretics was also associated with an increased risk of UGB (1.9; 1.7, 2.1). CONCLUSION: The use of spironolactone is associated with increased risk of UGB. The risk increases with higher doses.

Effect of a community screening for Helicobacter pylori: a 5-Yr follow-up study.

BACKGROUND: Helicobacter pylori (H. pylori) screening and eradication may reduce the incidence of gastric cancer, AND AIMS: peptic ulcer, and ulcer complications, and it may reduce symptoms in a small proportion of individuals with functional dyspepsia. This study aimed to assess the effect of community H. pylori screening and treatment on the prevalence of dyspepsia, and as secondary outcomes, the effect on dyspepsia-related health-care consumption and quality of life over 5 yr. METHODS: In 1998-1999, individuals aged 40-65 yr were randomized to H. pylori screening and treatment or to the control group. Five years later, the participants were sent a questionnaire to assess the prevalence of dyspepsia and quality of life. In addition, we obtained information from registers on the use of endoscopies and prescription medication. An economic evaluation was done alongside the randomized trial. RESULTS: Of 12,530 participants attending the study at baseline, 11,065 (88%) were traced and contacted at the 5-yr follow-up. The response rate was 94%. At baseline, 17.5% in the screened group were H. pylori-positive. The absolute reduction in dyspepsia during the first year was 4% in the screened group, whereas no change was observed in the unscreened group; this rate remained constant during the next 4 yr. Quality of life did not change. A small effect was found for dyspepsia-related consultations and sick leave days, but not on the prescription rate of ulcer drugs. A 33% lower ulcer incidence (107 ulcers vs 148 ulcers) was seen in the screened group compared to the unscreened group. CONCLUSION: A population H. pylori screening and treatment program in an H. pylori low-prevalence area had only a modest, but insignificant, effect on the rate of dyspepsia, and a modest, significant effect on the consultation rate and sick leave days for dyspepsia, but resulted in a decreased ulcer incidence. The intervention resulted in an increased cost due to H. pylori screening and treatment.