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 Barrett's 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 Barrett's 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.

Cost-effectiveness of antibiotics for COPD management: observational analysis using CPRD data.

It is often difficult to determine the cause of chronic obstructive pulmonary disease (COPD) exacerbations, and antibiotics are frequently prescribed. This study conducted an observational cost-effectiveness analysis of prescribing antibiotics for exacerbations of COPD based on routinely collected data from patient electronic health records. A cohort of 45 375 patients aged 40 years or more who attended their general practice for a COPD exacerbation during 2000-2013 was identified from the Clinical Practice Research Datalink. Two groups were formed ("immediate antibiotics" or "no antibiotics") based on whether antibiotics were prescribed during the index general practice (GP) consultation, with data analysed according to subsequent healthcare resource use. A cost-effectiveness analysis was undertaken from the perspective of the UK National Health Service, using a time horizon of 4 weeks in the base case. The use of antibiotics for COPD exacerbations resulted in cost savings and an improvement in all outcomes analysed; i.e. GP visits, hospitalisations, community respiratory team referrals, all referrals, infections and subsequent antibiotics prescriptions were lower for the antibiotics group. Hence, the use of antibiotics was dominant over no antibiotics. The economic analysis suggests that use of antibiotics for COPD exacerbations is a cost-effective alternative to not prescribing antibiotics for patients who present to their GP, and remains cost-effective when longer time horizons of 3 months and 12 months are considered. It would be useful for a definitive trial to be undertaken in this area to determine the cost-effectiveness of antibiotics for COPD exacerbations.

A review of the clinical and economic impact of using esomeprazole or lansoprazole for the treatment of erosive esophagitis.

BACKGROUND: The use of proton pump inhibitors (PPIs) for the treatment of erosive esophagitis has had a major impact on the prescribing budgets of primary care organizations in the United Kingdom. Assessments of the clinical and economic effectiveness of PPIs would provide useful tools for decision-making. OBJECTIVE: The goal of this study was to review the available preclinical and clinical studies comparing esomeprazole with lansoprazole in the healing and maintenance of erosive esophagitis, and to compare the budgeting impact of the 2 strategies. Comparative tolerability was also reviewed. METHODS: MEDLINE (1966-September 2002) and EMBASE (1980-September 2002) were searched for abstracts and articles reporting comparative studies of esomeprazole and lansoprazole. The search terms used were gastroesophageal reflux disease, reflux esophagitis, and proton pump inhibitor; all comparisons of esomeprazole and lansoprazole at any dose were considered. The database search was supplemented based on the authors' familiarity with the literature. RESULTS: The comparative studies that were identified fell into 4 categories: (1) intragastric acid suppression studies; (2) randomized controlled trials in the healing of erosive esophagitis; (3) randomized controlled trials in the maintenance of erosive esophagitis; and (4) health economic analyses. Based on these studies, when healing doses (esomeprazole 40 mg once daily, lansoprazole 30 mg once daily) and low doses (20 and 15 mg once daily, respectively) were compared, esomeprazole was more efficacious than lansoprazole in suppressing acid in the intragastric compartment (both comparisons, P < 0.05). More patients with erosive esophagitis experienced healing at 4 and 8 weeks with esomeprazole 40 mg once daily than with lansoprazole 30 mg once daily (P < 0.001 at 4 and 8 weeks). At 6 months, remission was maintained in more patients receiving esomeprazole 20 mg once daily than in those receiving lansoprazole 15 mg once daily (P < 0.001). No significant differences in tolerability were noted in clinical trials that directly compared the 2 PPIs. When the cost-effectiveness of esomeprazole treatment was compared with that of lansoprazole treatment in the healing and maintenance of erosive esophagitis, the greater efficacy of esomeprazole translated into potential cost savings and better outcomes. CONCLUSION: The currently available comparative data for esomeprazole and lansoprazole indicate clinical and cost-effectiveness advantages for esomeprazole in the healing and maintenance of erosive esophagitis compared with lansoprazole.

Gastro-oesophageal reflux disease.

Part two of this article on GORD examines investigations and treatment options once the initial diagnosis of the condition has been made and focuses on the role that nurses can play in helping patients with this condition.

Difficulties in the interpretation of lung function tests in the diagnosis of asthma and chronic obstructive pulmonary disease.

OBJECTIVE: To ascertain differences in the interpretation of spirometry and peak flow measurement between primary care (several practioners and nurses) and specialists in patients with a pre-existing diagnosis of asthma and chronic obstructive pulmonary disease (COPD). DESIGN: A randomized, prospective cohort study of 98 patients with a pre-existing diagnosis of asthma or COPD. Two chest specialists independently interpreted the peak flow and spirometric data and they were also blinded to the primary care results. RESULTS: There was total agreement in interpretation of the data between general practitioners and specialists in only 20 (20.4%). Levels of diagnostic agreement were highest between the two chest specialists (55%) and lowest between the general practice records and the diagnosis assigned by general practitioners (16%). Disagreement between general practitioners and the two chest specialists was consistent (38%) indicating systematic differences in interpretation. CONCLUSIONS: This study raises concerns about differences in the interpretation of spirometry and peak expiratory flow rates in general and hospital practice and the guidelines on which these interpretations are based.

Beyond heartburn: a systematic review of the extra-oesophageal spectrum of reflux-induced disease.

BACKGROUND: Gastro-oesophageal reflux disease (GORD) is a chronic condition affecting up to one-quarter of the Western population. GORD is characterized by heartburn and acid regurgitation, but is reported to be associated with a spectrum of extra-oesophageal symptoms. OBJECTIVE: The aim of this systematic review was to critically evaluate postulated extra-oesophageal symptoms of GORD. METHODS: Extra-oesophageal symptoms were identified from population-based studies evaluating their association with GORD (either defined as heartburn and/or acid regurgitation, or diagnosed in general practice). The response of these symptoms to acid-suppressive therapy was investigated using randomized, double-blind, placebo-controlled studies. Pathogenic mechanisms were evaluated using clinical and preclinical studies. RESULTS: An association between GORD and symptoms or a diagnosis of chest pain/angina, cough, sinusitis and gall-bladder disease was evident from three eligible population-based studies of GORD. Randomized placebo-controlled studies (n=20) showed that acid-suppressive therapy provides symptomatic relief of chest pain, asthma and, potentially, chronic cough and laryngitis. Mechanistic models, based on direct physical damage by refluxate or vagally mediated reflexes, support a causal role for GORD in chest pain and respiratory symptoms, but not in gall-bladder disease. CONCLUSION: GORD is likely to play a causal role in chest pain and possibly asthma, chronic cough and laryngitis. Further investigation is desirable, particularly for other potential extra-oesophageal manifestations of GORD such as chronic obstructive pulmonary disease, sinusitis, bronchitis and otitis. Acid-suppressive therapy is likely to benefit patients with non-cardiac chest pain, but further placebo-controlled studies are needed for other symptoms comprising the extra-oesophageal spectrum of GORD.

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.

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

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.