H pylori status was evaluated in 147 of the 692 patients (21%). In most of these cases the correspondence between the hospital staff and the GP did not mention current H pylori status. In addition, it remained unknown whether eradication therapy was administered with or without successful eradication of the microorganism (Table 3).
No investigations were performed in 230 of the 922 patients (25%). “Nonspecific stomach com-plaints” was the most common indication for ASDs in this group (Table 2).
TABLE 2
INDICATIONS FOR LONG-TERM (≥ 12 WEEKS) PRESCRIPTION OF LONG-TERM ACID SUPPRESSANT DRUGS
| No. (%) | |
|---|---|
| Final Diagnosis | 692 (75) |
| I-ULCER* | 271 (29) |
| Duodenal ulcer | 196 (21) |
| Duodenal and gastric ulcer | 17 (2) |
| Gastric ulcer | 43 (5) |
| Nonspecified ulcer | 15 (2) |
| I-GERD | 342 (37) |
| Esophagitis and ulcer* | 48 (5) |
| Esophagitis | 116 (13) |
| Esophagitis and hiatal hernia | 101 (11) |
| Symptomatic (hiatal hernia) | 77 (8) |
| I-FUNCTIONAL | 127 (14) |
| NI: Stomach Complaints | |
| Not Investigated | 230 (25) |
| Preventive | 45 (5) |
| Nonspecific stomach complaints | 146 (16) |
| Refluxlike complaints | 27 (3) |
| Ulcerlike complaints | 6 (1) |
| Motilitylike complaints | 6 (1) |
| Group I-ULCER includes all patients with a duodenal, gastric, or nonspecified ulcer; group I-GERD includes all patients with symptomatic or erosive gastroesophageal reflux disease; group I-FUNCTIONAL includes patients with only gastritis or with no imaging abnormalities. No investigations were performed on patients in group NI. | |
| *Total equals more than 100% because 48 patients with esophagitis and ulcer disease are included in both I-ULCER and I-GERD. | |
TABLE 3
H PYLORI DIAGNOSTICS AND ERADICATION THERAPY PRESCRIPTIONS IN 692 INVESTIGATED PATIENTS*
| Final Diagnoses After Investigation† | H pylori Diagnostics Ordered, No. (%) | H pylori Eradication Therapy Prescribed, No.(%) |
|---|---|---|
| I-ULCER (n = 271) | 78 (29) | 34 (13) |
| I-GERD (n = 342) | 34 (10) | 7 (2) |
| I-FUNCTIONAL (n = 127) | 35 (28) | 7 (6) |
| * The current H pylori status, prescription, and success of eradication therapy often remained unknown. Group I-ULCER includes all patients with a duodenal, gastric, or nonspecified ulcer; group I-GERD includes all patients with symptomatic or erosive gastroesophageal reflux disease; group I-FUNCTIONAL includes patients with only gastritis or with no imaging abnormalities. | ||
| † Forty-eight patients with gastroesophageal reflux disease and ulcer disease were included in both I-ULCER and I-GERD. | ||
Discussion
During our 1-year study, 2% of patients used an ASD for more than 3 months, and 0.8% for more than 6 months. Data from other studies, although not entirely comparable with ours, give an impression of the magnitude of long-term ASD prescription in other countries. In London, 0.8% of the general practice population used an ASD for more than 6 months continuously, a situation comparable with our results.5 One third of these patients had a history of ulcer disease. In Dundee, 4.4% of patients in 6 gen-eral practices were authorized to receive maintenance therapy.6 Many had a history of confirmed ulcer disease (27%), esophagitis (23%), or both (6%). Investigations in 23% of all patients revealed gastritis, duodenitis, hiatal hernia, or no pathology.
ASDs were used continuously for more than 1 year by almost one fourth of patients for whom they were prescribed; prolongation of the prescription was usually based on diagnostic tests performed years before. According to the guidelines that were in use during the course of this study, the indication for maintenance ASD was justified for most patients.2
Almost one third of all patients had a history of ulcer and continued to take an ASD (only 48 had concomitant GERD). For most of them, the ASD was probably prescribed as a preventive treatment. H pylori diagnostics were performed in a minority of patients. The major change in the most recent version of the guidelines of the Dutch College of General Practitioners (1996) is the role of H pylori infection. Patients with duodenal ulcer (active or inactive) not caused by NSAID use should be treated with H pylori eradication therapy.7 In principle, long-term ASD use is not necessary after successful eradication of H pylori, since the ulcer is not likely to relapse.8,9 However, a few patients with severe concomitant symptoms of functional dyspepsia or reflux disease may require therapy despite successful H pylori eradication.9,10 It is the GP’s task to identify patients with a history of ulcer disease and to eradicate H pylori. The clinician can easily identify patients with a history of ulcer disease with the help of computerized prescription data and the patient’s history file. However, implementation of these systems remains an important issue. Many such patients are invisible to the GP because they are treated with repeated prescriptions and without further consultation and therefore are not treated for H pylori.
The current Dutch guidelines do not advise testing for H pylori in patients with GERD or functional dyspepsia; this approach, therefore, is still not common in the Netherlands. Not advising to test is consistent with guidelines developed with a primary care perspective but differs in fundamental ways from guidelines formulated by specialists.11,12 The role of H pylori in esophagitis and reflux disease is not clear.13 Whether successful eradication of H pylori leads to exacerbation of esophagitis because of the absence of acid buffering by H pylori–derived urease production has been debated.14 In our study, one third of the patients suffered from GERD, which is easy to control, but not to cure; patients often experience a relapse after tapering of ASDs. Intermittent treatment with ASDs and the use of antacids as an escape medication may be an effective approach for managing patients with uncomplicated GERD and reducing the use of ASDs.15,16