It is uncertain how to manage patients with a partial symptomatic response. There is no set definition for a partial response; however, it can typically be defined by one or more of the following: incomplete symptom control, return clinic visits or unwillingness to continue prescribed therapy. Medication compliance may play a role because there is a theoretical advantage to the administration of PPI once a day (in the case of a single standard dose) given 30 min to 60 min before breakfast, the time when acid pumps are most readily blocked. Continue reading
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In the case of a patient (either heartburn-dominant or nonheartburn-dominant H pylori-negative) with only partial or no symptom response to a course of standard-dose acid suppression, the CMT recommends to increase the degree of acid suppression to a PP1 if an H2RA was given, increase the dose of a PP1 to twice a day, or treat for a further four to eight weeks with the same dose. There are no clinical trial data for the last approach. 1f a patient fails to improve with a course of double-dose PP1 for four to eight weeks, it is unlikely that the symptoms are acid-sensitive, and the PP1 should be discontinued, symptoms reviewed and the patient investigated further (eg, endoscopy). It’s time for you to start saving some money: you just need to visit the pharmacy that offers finest quality amaryl diabetes with delivery straight to your door and all the confidentiality guarantees you ever need. Continue reading
The CMT was published in June 2000 when the prokinetic agent cisapride was still available. This agent has since been withdrawn from most markets due to rare but possibly life-threatening cardiac arrhythmias. Cisapride is currently available only under special authorization for patients with severe gastroparesis; it should not be used for the treatment of dyspepsia. For the two other available prokinetic agents (dom-peridone and metoclopramide), there is very limited evidence regarding efficacy in dyspepsia. Continue reading
The CMT recommends treatment for four to eight weeks with a PPI or H2RA for H pylori-negative patients who are not using NSAIDs or ASA, and whose symptoms do not suggest GERD. There is evidence that, for this patient group, a PPI provides superior efficacy compared with an H2RA or a proki-netic agent. As well, a greater proportion of patients will respond after eight weeks of treatment, compared with after four weeks. You should always visit the best pharmacies to get your medications cheap and safely. You will find this *pharmacy to be particularly advantageous and safe, buying any drugs required in just a few minutes.
Few long-term efficacy studies have been published in H pylori-negative dyspepsia patients; however, available data indicate that PPIs provide better efficacy compared with ^RAs. The CADET H pylori-negative (CADET-HN) study compared a PP1, an H2RA, a prokinetic agent and placebo in uninvestigated H pylori-negative dyspepsia patients. Continue reading
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1. Patients who have ongoing or recurrent dyspepsia symptoms following H pylori treatment should be tested by UBT (not serology) or undergo endoscopy with biopsies to determine whether H pylori is present.
Voting on recommendation (level/vote)
- C to E/0
Level of evidence I
Classification of recommendation A Continue reading
Serology is not an acceptable follow-up test because antibodies may remain detectable for over 12 months despite successful cure of the infection . If UBT is not available, endoscopy with biopsies may be performed to document cure if the endoscopy is clinically indicated. Should the patient continue to be H pylori-positive, retreatment with an alternative eradication therapy is recommended.
In Canada, the success rate of H pylori eradication treatment is high (75% to 85%) and, therefore, it is likely that, once treated, patients will become H pylori-negative. Acid suppressive therapy is the treatment of choice for ongoing symptoms, and it is reasonable to start this treatment as soon as the patient returns for management of symptoms rather than awaiting the results of further H pylori testing. Continue reading
The most frequently used diagnostic test for H pylori infection is serology. The UBT is recommended because it has a higher positive predictive value (predicting the true presence of infection) and negative predictive value (predicting the true absence of infection) compared with serology, over a broad infection prevalence range . However, the UBT is not readily available across Canada and access may be limited due to lack of reimbursement. For serology, the negative predictive value is high (over 90%) while the positive predictive value is reduced to 70% to 80%, especially in individuals less than 40 years of age who have a lower (less than 20%) H pylori prevalence. This means that when serology is used, a significant proportion of patients will be treated based on false-positive test results. Continue reading
Regarding the duration of eradication treatment, the recommendation continues to be seven to 10 days for the first treatment. Recent data suggest that bismuth-based quadruple therapy may be as effective as PPI-based triple therapy and, therefore, could be considered as an alternative first-line therapy. However, this therapy is more complicated and involves taking 18 tablets a day. All PPIs available in Canada (esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole) have similar efficacy in curing H pylori with combinations of clarithromycin-metronidazole or clarithromycin-amoxicillin. Eradication failure is a concern because PPI-clarithromycin-amoxicillin or PPI-clarithromycin-metronidazole combinations are not successful in 15% to 25% of cases. Continue reading
A post hoc subgroup analysis suggested that, in a small population of patients, heartburn symptoms will improve after H pylori eradication. The benefit of curing H pylori has been supported in other studies as well. The benefits of the test-and-treat approach are probably derived mainly from treatment of underlying ulcer disease and possibly improving a small proportion of functional dyspepsia patients . The lifetime risk in an H pylori-infected individual to develop ulcers is 5% to 15% . It is important to note that, despite successful treatment of the infection, a substantial proportion of patients (at least 50%) will require ongoing treatment for dyspepsia symptoms. Continue reading
Recommendations for management of patients with nonheartburn-dominant dyspepsia and H pylori infection
The CMT recommendation for patients with dyspepsia who are not using NSAIDs or ASA and who do not have dominant symptoms of heartburn is a noninvasive test for H pylori, and treatment if the test is positive. The CADET H pylori (CADET-Hp) study compared a one-week PPl-based eradication regimen with placebo (empirical twice-a-day PP1) treatment given for one week, to determine whether H pylori treatment does lead to long-term improvement in dyspepsia symptoms. This study of 296 patients showed that there was symptomatic improvement at 12 months in 50% of patients, in whom H pylori infection was cured, compared with 36% of controls with persistent infection (P=0.02). Continue reading