The efficacy of proton pump inhibitors in nonulcer dyspepsia: a systematic review and economic analysis

Editorial: Reflux, dyspepsia, and Rome III (or Rome IV?)

The paper by Xiao et al. in this issue of American Journal of Gastroenterology reports that patients with functional dyspepsia (FD) complaining of epigastric burning have a higher probability to present abnormal gastroesophageal acid reflux, as well as response to proton pump inhibitor therapy than those complaining of epigastric pain, bothersome postprandial fullness, or early satiety. No differences in the above parameters were detected when comparing patients with epigastric pain syndrome and postprandial distress syndrome, as proposed by the Rome III classification of FD. If confirmed, these results contribute to clarify the relationship between FD and gastroesophageal reflux disease and, at the same time, highlight the importance of analyzing individual symptoms rather than clusters of symptoms, when managing patients complaining of upper gastrointestinal symptoms.

Current medical treatments of dyspepsia and irritable bowel syndrome

Dyspepsia is a highly prevalent condition characterized by symptoms originating in the gastroduodenal region without underlying organic disorder. Treatment modalities include acid-suppressive drugs, gastroprokinetic drugs, Helicobacter pylori eradication therapy, tricyclic antidepressants, and psychological therapies. Irritable bowel syndrome is a multifactorial, lower functional gastrointestinal disorder involving disturbances of the brain-gut axis. The pathophysiology provides the basis for pharmacotherapy: abnormal gastrointestinal motor functions, visceral hypersensitivity, psychosocial factors, intraluminal changes, and mucosal immune activation. Medications targeting chronic constipation or diarrhea may also relieve irritable bowel syndrome. Novel approaches to treatment require approval, and promising agents are guanylate cyclase cagonists, atypical benzodiazepines, antibiotics, immune modulators, and probiotics.

Meta-analysis: the effects of placebo treatment on gastro-oesophageal reflux disease

BACKGROUND

There appears to be a significant placebo response rate in clinical trials for gastro-oesophageal reflux disease. Little is known about the determinants and the circumstances associated with placebo response in the treatment of gastro-oesophageal reflux disease (GERD).

AIMS

To estimate the magnitude of the placebo response rate in randomized controlled trials for GERD and to identify factors that influence this response.

METHODS

A meta-analysis of randomized, double-blind, placebo-controlled trials, published in English language, which included >20 patients with GERD, treated with either a proton pump inhibitor or H(2)-receptor antagonist for at least 2 weeks. Medline, Cochrane and EMBASE databases were searched, considering only studies that reported a global response for 'heartburn'.

RESULTS

A total of 24 studies included 9989 patients with GERD. The pooled odds ratio (OR) for response to active treatment vs. placebo was 3.71 (95% CI: 2.78-4.96). The pooled estimate of the overall placebo response was 18.85% (range 2.94%-47.06%). Patients with erosive oesophagitis had a non-significantly lower placebo response rate than patients without it (11.87% and 18.31%, respectively; P = 0.246). Placebo response was significantly lower in studies of PPI therapy vs. studies of H(2) RAs (14.51% vs. 24.69%, respectively; P = 0.05).

CONCLUSIONS

The placebo response rate in randomized controlled trials for GERD is substantial. A lower placebo response was associated with the testing of PPIs, but not the presence of erosive oesophagitis.

Clinical trial: dose-dependent therapeutic efficacy of acotiamide hydrochloride (Z-338) in patients with functional dyspepsia - 100 mg t.i.d. is an optimal dosage

BACKGROUND

Acotiamide is a selective acetylcholinesterase inhibitor and enhances the actions of cholinergic neurons localized in the stomach.

METHODS

The present two studies were conducted to examine the optimal dosage of acotiamide hydrochloride (Z-338) in patients with functional dyspepsia (FD) in Japan.

KEY RESULTS

The improvement rate of 'subjects global assessment of overall treatment efficacy (OTE)' at the final evaluation was approximately 10% higher in the acotiamide 100 mg group than that in the placebo group with good reproducibility though there was no significant differences at primary endpoint. The elimination rate of postprandial fullness in the acotiamide 100 mg group was significantly higher compared to placebo group. In addition, the post hoc analysis showed that in patients whose main complaints are meal-related symptoms such as postprandial fullness, upper abdominal bloating and/or early satiety, the improvement rate of 'OTE' at final evaluation in acotiamide 100 mg group was significantly superior to that in the placebo group.

CONCLUSIONS & INFERENCES

These results suggest that acotiamide possesses efficacy on FD and more specifically its meal-related symptoms of FD.

Observational comparative trial of the efficacy of proton pump inhibitors versus histamine-2 receptor antagonists for uninvestigated dyspepsia

BACKGROUND AND AIMS

It is still controversial which drugs, proton pump inhibitors (PPI) or histamine-2 receptor antagonists (H2RA), are more effective for dyspepsia in the Japanese population.

METHODS

Patients with uninvestigated dyspepsia (n = 104; male/female 41/63) were treated with either rabeprazole 10 mg o.d. (n = 62) or lafutidine 10 mg b.i.d. (n = 42) for 4 weeks. Questionnaires (modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease [mFSSG] and quality of life [QOL], SF-8) were administered before and after therapy. The mFSSG was classified into a total score (Q-T), reflux score (Q-R), dyspepsia score (Q-D) and pain score (Q-P). The SF-8 had a physical component summary (PCS) and mental component summary (MCS). The predominant type of symptom was reflux (R-S), pain (P-S) or dysmotility (D-S).

RESULTS

R-S was 19.2%, P-S 48.1%, D-S 24.0% and overlap 8.7%. In the R-S, Q-T and Q-R significantly improved with rabeprazole, but neither scale improved with lafutidine. MCS significantly improved with rabeprazole. In P-S, Q-T, Q-R, Q-D and Q-P significantly improved with both drugs. PCS significantly improved with both, whereas the MCS significant improved with rabeprazole. In D-S, Q-R and Q-D significant improved with rabeprazole, but neither improved with lafutidine. QOL did not improve with either. With overlap, neither scale nor the QOL reached a significant difference.

CONCLUSION

Both PPI and H2RA have a positive effect on P-S, but H(2)RA therapy is limited for R-S and D-S, whereas PPI therapy is generally effective. Therefore, careful prescription based on symptoms is important.

[Symptom profile in gastroesophageal reflux disease in untreated patients and those with persistent symptoms despite treatment]

AIM

1. To analyze the symptom profile of gastroesophageal reflux disease (GERD) with typical clinical manifestations (heartburn and/or regurgitation); 2. to compare untreated patients with those with persistent symptoms despite treatment; 3. to evaluate severity according to physicians' and patients' opinions; and 4. to determine the diagnostic and therapeutic approaches used.

METHODS

We performed a prospective, observational, cross-sectional study under conditions of standard clinical practice.

RESULTS

A total of 2356 patients were included. Dyspeptic symptoms were highly frequent (close to 90% in both groups) and supraesophageal symptoms were also common (50-60%). Patients with persistent symptoms despite treatment were older, and had more supraesophageal symptoms; in addition, the typical supraesophageal and dyspeptic symptoms of GERD were more severe in these patients. Severity evaluations by patients and doctors were concordant but patients considered severity to be greater. Older age was a risk factor for supraesophageal symptoms, female gender for dyspeptic symptoms and body mass index for greater severity of GERD symptoms. Endoscopy was requested in about 60% of the patients. Diet counseling was advised in most patients and postural recommendations were made in more than half. Proton pump inhibitors were prescribed in almost all patients, and were associated with prokinetics and/or antacids in many patients.

CONCLUSIONS

Dyspeptic symptoms should not be considered as independent of GERD, and typical and atypical symptoms are associated in 50% of patients. Gastroenterologists follow clinical practice guidelines fairly closely but diagnostic procedures seem to be overindicated.

Is Chios mastic gum effective in the treatment of functional dyspepsia? A prospective randomised double-blind placebo controlled trial

BACKGROUND

Herbal remedies are increasingly popular for the treatment of functional dyspepsia. Chios mastic gum is a resinous exudate from the stem of Pistacia lentiscus var. chia. It is a traditional natural remedy used throughout the eastern Mediterranean. The aim of this study was to assess the efficacy of Chios mastic gum in patients with functional dyspepsia.

METHODS

One hundred and forty eight patients fulfilling Rome II criteria for functional dyspepsia were randomly assigned to receive either Chios mastic gum 350 mg three times daily or placebo. After 3 weeks of treatment the change from baseline in the severity of symptoms of functional dyspepsia was assessed using the Hong Kong index of dyspepsia. Patients' global assessment of efficacy was also evaluated.

RESULTS

The symptom score after treatment was significantly lower in the Chios mastic gum than in the placebo group ((14.78+/-1.78) vs (19.96+/-1.83)) (p<0.05). There was a marked improvement of symptoms in 40% of patients receiving placebo and in 77% of patients receiving Chios mastic gum (p<0.02). Individual symptoms that showed significant improvement with Chios mastic gum were: stomach pain in general, stomach pain when anxious, dull ache in the upper abdomen and heartburn (<0.05 for all four symptoms).

CONCLUSION

Chios mastic gum significantly improves symptoms in patients with functional dyspepsia compared to placebo.

Managing dyspepsia

The prevalence of dyspepsia in the general population is as high as 40%, and its management represents a considerable financial burden to the health care system. Causes of dyspepsia amenable to medical therapy include peptic ulcer and functional dyspepsia, and testing for Helicobacter pylori and treating positive individuals is beneficial in both conditions. Individuals presenting for the first time with uninvestigated dyspepsia, age greater than 50 years, or alarm features require upper gastrointestinal (GI) endoscopy to exclude gastroesophageal malignancy. Upper GI endoscopy for younger individuals without alarm features is not cost-effective compared with the "test and treat" approach. Test and treat and empirical acid-suppression using a proton pump inhibitor (PPI) have similar costs and effects. Recent evidence suggests that empirical acid suppression commencing with antacids is as effective as PPI. Screening and treatment of H. pylori in PPI users and the community may reduce the costs of managing dyspepsia.

Systematic reviews: the good, the bad, and the ugly

Systematic reviews systematically evaluate and summarize current knowledge and have many advantages over narrative reviews. Meta-analyses provide a more reliable and enhanced precision of effect estimate than do individual studies. Systematic reviews are invaluable for defining the methods used in subsequent studies, but, as retrospective research projects, they are subject to bias. Rigorous research methods are essential, and the quality depends on the extent to which scientific review methods are used. Systematic reviews can be misleading, unhelpful, or even harmful when data are inappropriately handled; meta-analyses can be misused when the difference between a patient seen in the clinic and those included in the meta-analysis is not considered. Furthermore, systematic reviews cannot answer all clinically relevant questions, and their conclusions may be difficult to incorporate into practice. They should be reviewed on an ongoing basis. As clinicians, we need proper methodological training to perform good systematic reviews and must ask the appropriate questions before we can properly interpret such a review and apply its conclusions to our patients. This paper aims to assist in the reading of a systematic review.

Functional gastrointestinal disorders: past and present

BACKGROUND

Chronic abdominal pain is a common complaint in childhood and adolescence. Despite decades of clinical observations and research, it still poses a challenge to pediatric health care professionals. The aim of this review is to highlight the epidemiology of pediatric chronic abdominal pain and to describe the pathogenesis of this disorder, its clinical manifestations, evaluation and therapeutic options.

DATA SOURCES

Articles on chronic abdominal pain in the recent years from PubMed, MEDLINE, and reference textbooks were reviewed.

RESULTS

Chronic abdominal pain, a functional gastrointestinal disorder (FGID), is a multifactorial condition that results from a complex interaction between psychosocial and physiologic factors via the brain-gut axis. A thorough history coupled with a complete physical examination and normal screening studies rule out an organic cause in 95% of the cases. It is highly important for the physician to establish a trusting relationship with the child and parents because successful treatment including modification of physical and psychological stress factors, dietary changes, and drug therapy depends greatly on education, reassurance and active psychological support.

CONCLUSIONS

FGIDs are a cause of great anxiety, distress and morbidity in children as well as adults. As our understanding of these conditions improves, our therapeutic interventions will progress not only to overcome them but also to intervene early in the disease course so as to limit long-term impact.

Adherence to best practice guidelines in dyspepsia: a survey comparing dyspepsia experts, community gastroenterologists and primary-care providers

BACKGROUND

Although 'best practice' guidelines for dyspepsia management have been disseminated, it remains unclear whether providers adhere to these guidelines.

AIM

To compare adherence to 'best practice' guidelines among dyspepsia experts, community gastroenterologists and primary-care providers (PCPs).

METHODS

We administered a vignette survey to elicit knowledge and beliefs about dyspepsia including a set of 16 best practices, to three groups: (i) dyspepsia experts; (ii) community gastroenterologists and (iii) PCPs.

RESULTS

The expert, community gastroenterologist and PCP groups endorsed 75%, 73% and 57% of best practices respectively. Gastroenterologists were more likely to adhere with guidelines than PCPs (P < 0.0001). PCPs were more likely to define dyspepsia incorrectly, overuse radiographic testing, delay endoscopy, treat empirically for Helciobacter pylori without confirmatory testing and avoid first-line proton pump inhibitors (PPIs). PCPs had more concerns about adverse events with PPIs [e.g. osteoporosis (P = 0.04), community-acquired pneumonia (P = 0.01)] and higher level of concern predicted lower guideline adherence (P = 0.04).

CONCLUSIONS

Gastroenterologists are more likely than PCPs to comply with best practices in dyspepsia, although compliance remains incomplete in both groups. PCPs harbour more concerns regarding long-term PPI use and these concerns may affect therapeutic decision making. This suggests that best practices have not been uniformly adopted and persistent guideline-practice disconnects should be addressed.

Hypnosis and upper digestive function and disease

Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions, hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential influence of hypnosis on upper digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of upper digestive motor and secretory function. The present evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases of the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.

Pediatric functional gastrointestinal disorders

Functional gastrointestinal disorders continue to be a prevalent set of conditions faced by the healthcare team and have a significant emotional and economic impact. In this review, the authors highlight some of the common functional disorders seen in pediatric patients (functional dyspepsia, irritable bowel syndrome, functional abdominal pain) as well as one of the more intriguing (cyclic vomiting). The most recent Pediatric Rome Working Group has modified the definitions of functional gastrointestinal disorders. Current studies have used these categorizations to understand better the epidemiology, etiology, and treatment options for these disorders. As more data are available, children and their families will be offered a better understanding of the conditions and more effective treatments to overcome them. The importance of making an accurate diagnosis of a functional gastrointestinal disorder cannot be overemphasized.

Hip fracture and proton pump inhibitor therapy: balancing the evidence for benefit and harm

Gastroenterology is full of examples of drugs being enthusiastically promoted only to be withdrawn or prescription curtailed once the harms of the medication are realized. Cox-2 inhibitors, alosetron, and tegaserod are all recent examples of this phenomenon. The problem is that potential harms of drugs are being highlighted in the medical literature all the time and it can be difficult to determine whether these represent a genuine risk to our patients or are just spurious epidemiological associations. The association between proton pump inhibitor therapy and hip fracture is a good illustration of this dilemma. We use this example to highlight an approach that can be taken to critically evaluate the evidence for harms of medication.

Functional dyspepsia: past, present, and future

Functional dyspepsia (FD) is a highly prevalent gastrointestinal disorder characterized by symptoms originating from the gastroduodenal region in the absence of underlying organic disease that readily explains the symptoms. The Rome II consensus, which defined FD as the presence of unexplained pain or discomfort in the epigastrium, had a number of drawbacks, including an unjustified focus on pain, inclusion of a large number of nonspecific symptoms, and an unclear position on overlap with gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). The Rome III consensus redefined FD as the presence of epigastric pain or burning, postprandial fullness or early satiation in the absence of underlying organic disease. Frequent overlap with GERD and IBS is acknowledged but does not exclude a diagnosis of FD. A subgroup classification into postprandial distress syndrome and epigastric pain syndrome was proposed. Ongoing studies will clarify the impact of this subdivision on clinical management and treatment outcomes.

Exploratory Study of Tegaserod for Dyspepsia in Women Receiving PPIs for Heartburn

Background and Aims

Tegaserod is a selective serotonin receptor (5-HT₄) agonist that relieves dysmotility symptoms associated with constipation. Here we explore its effects on functional dyspepsia symptoms and heartburn during continued proton pump inhibitor (PPI) treatment.

Methods

In this multicenter pilot study, following a 2-week screening/baseline period, women with functional dyspepsia and persisting heartburn treated with PPIs received add-on open-label tegaserod 6 mg twice daily (bid) for 4 weeks. Treatment responders were then randomized 1:1 to continue double-blind tegaserod or placebo therapy for 6 weeks. Efficacy variables included the proportion of days with satisfactory relief of dyspepsia symptoms (early satiety, postprandial fullness and bloating) as well as the change in individual symptom severity scores for these three cardinal dyspepsia symptoms. Health-related quality of life was evaluated using a validated questionnaire, the Nepean Dyspepsia Index. Adverse events (AEs) were monitored.

Results

Of 101 women enrolled, 71 completed open-label treatment, and 70 responders were randomized to double-blind treatment. The proportion of days with satisfactory relief of dyspepsia symptoms (least squares mean, LSM) increased with tegaserod and placebo, to 0.69 and 0.62, respectively at study end (P = 0.366). Similarly, both groups showed improvements in the composite daily symptom severity score (overall LSM change from baseline of 1.55 and 1.57, P = 0.934), and the Nepean Dyspepsia Index (overall LSM change of −39.0 and −37.8, P = 0.537). Tegaserod was well tolerated. Diarrhea was the most common AE (8.1% tegaserod, 0% placebo). There were no serious AEs or deaths.

Conclusions

A significant treatment effect was not demonstrated in this study using a treatment-withdrawal methodology. In future studies of functional dyspepsia patients with heartburn, a more rigorous parallel-group study design should be considered.

Tegaserod in patients with mechanical sensitivity and overlapping symptoms of functional heartburn and functional dyspepsia

BACKGROUND

While functional heartburn (FH) and functional dyspepsia (FD) are recognized clinical entities, symptoms often overlap across both disorders. Despite their frequency, little is known of the underlying pathophysiology of overlapping symptoms. This study evaluated the effect of the 5-HT(4) agonist, tegaserod, on visceral sensitivity and symptom improvement in patients with overlapping symptoms of FH and FD.

RESEARCH DESIGN AND METHODS

Patients with overlapping symptoms of FH and FD (ROME II) and mechanical hypersensitivity (Barostat examination) were randomized to tegaserod 6 mg bid or placebo for 2 weeks with treatment crossover after a 2-week washout period. Esophageal and gastric Barostat sensory tests were performed and patients rated their overall symptoms at study end. When carry-over was detected, data were presented for period 1 only. Safety was also assessed.

RESULTS

Sixty patients were screened of whom 30 were randomized and 25 completed. Mechanical hypersensitivity was reported by 83% of 47 patients completing esophageal and gastric baseline Barostat examinations. Tegaserod did not significantly alter balloon volume to pain (primary variable); however, pressure to gastric pain increased (p = 0.044 vs. placebo). The severity of heartburn, regurgitation, early fullness, and bloating was significantly lower following tegaserod vs. placebo treatment (p = 0.026, p = 0.021, p = 0.016, and p = 0.030). Overall symptom improvement was reported by 52% tegaserod vs. 32% placebo patients (p = 0.275), and treatment was well tolerated.

CONCLUSIONS

Results suggest that tegaserod may increase the gastric pain threshold and decrease the severity of individual symptoms in patients with overlapping FH and FD. However, these findings must be considered within the context of the study limitations, including the small number of subjects, potential for and presence of a carry-over effect, along with the impact of Barostat balloon use on the assessment of gastric function.

Efficacy and safety of pantoprazole 20 mg once daily treatment in patients with ulcer-like functional dyspepsia

OBJECTIVE

To investigate the efficacy of pantoprazole 20 mg once daily (o.d.) in relieving epigastric pain associated with ulcer-like functional dyspepsia.

RESEARCH DESIGN AND METHODS

In this double-blind, placebo-controlled, multicentre study, patients experiencing ulcer-like functional dyspepsia, with epigastric pain as the predominant symptom, were randomised to receive pantoprazole 20 mg or placebo o.d. for 28 days. Primary endpoint was the complete relief (i.e. absence) from epigastric pain after 28 days' treatment. The odds ratio (OR) for pantoprazole/placebo and its 95% confidence intervals (CIs) were determined. Significant superiority of pantoprazole was concluded if the value 1.0 was above this interval.

RESULTS

Of 419 patients (intention-to-treat [ITT]) randomised to treatment, 207 received pantoprazole and 212 received placebo. Epigastric pain relief was achieved after 28 days' treatment in 55% of pantoprazole recipients and 45% of placebo recipients (per-protocol [PP]: 58% and 47%, respectively). Pantoprazole demonstrated statistically significant superiority compared with placebo in the ITT (OR: 0.68; 95% CI: 0.46-0.99) and PP populations (OR: 0.64; 95% CI: 0.42-0.98). Pantoprazole was more efficacious than placebo in relieving heartburn and acid regurgitation after 7, 14 and 28 days of treatment. The sum score of gastrointestinal symptoms after 28 days was statistically significantly lower in the pantoprazole than placebo group. Fewer patients receiving concomitant psychotropic medication experienced relief from epigastric pain than those not receiving such medication. Adverse events did not significantly differ between pantoprazole and placebo.

CONCLUSIONS

Results of this study suggest that pantoprazole 20 mg is more efficacious than placebo, and is a well-tolerated treatment for relieving epigastric pain in patients with ulcer-like functional dyspepsia. Further research is needed to confirm these findings.

Clinical trial: a randomized controlled cross-over study of flupenthixol + melitracen in functional dyspepsia

BACKGROUND

Functional dyspepsia is a prevalent condition associated with diminished quality of life (QoL) and high economic burden.

AIM

To study the efficacy of a combination of flupenthixol and melitracen (F + M) with anxiolytic and antidepressant properties in functional dyspepsia using a randomized controlled cross-over design.

METHODS

Patients met the Rome III criteria for functional dyspepsia and a validated questionnaire was used to exclude those with anxiety or depression. Moreover, patients had to have failed a trial of acid-suppressive therapy and Helicobacter pylori eradication when positive. End points included subjective global symptom relief and QoL assessed by the Nepean Dyspepsia Index (NDI).

RESULTS

Twenty-five patients (14 females, 11 males; mean age = 34.3 +/- 9.9 years) were enrolled and 24 completed the 8-week study. There was a significant improvement in subjective global symptom relief with F + M vs. placebo (ITT: 73.9% vs. 26.1%, P = 0.001) and a significant drop in the NDI score vs. placebo (ITT: -9.0 +/- 11.9 vs. -2.4 +/- 8.9, P = 0.03). No difference was noted whether the initial treatment was F + M or placebo. No significant side effects were noted.

CONCLUSIONS

A combination of F and M is safe and effective in the short-term treatment of functional dyspepsia. F + M is associated with significant improvement in QoL independent of the presence of anxiety or depression.

Proton pump inhibitors for dyspepsia

Proton pump inhibitors are widely used in many upper gastrointestinal disorders. Dyspepsia is a common problem in primary care and endoscopy is neither feasible nor affordable in the majority of patients. Helicobacter pylori eradication has been shown to be effective, but with the declining prevalence of H. pylori infection in Western countries, alternate strategies are necessary. Proton pump inhibitor therapy is one such alternative and has already been adopted in dyspepsia management guidelines in the USA, UK and Canada. Cost-effectiveness studies suggest that in young patients acid suppression alone is more cost-effective than either endoscopy or testing and treatment for H. pylori in areas with a low prevalence of H. pylori.

Current treatments in functional dyspepsia

By nature of the definition of functional dyspepsia (FD), organic causes have to be ruled out before therapy can be directed. However, in uninvestigated dyspepsia in the absence of alarm features, Helicobacter pylori "test and treat" or an empiric trial of acid suppression therapy for 4 to 8 weeks is reasonable. If alarm symptoms or signs are present, or if the dyspepsia symptoms first occur in those aged greater than 55 years, prompt esophagogastroduodenoscopy is mandatory to exclude serious disease and positively diagnose FD. Empiric acid suppression with H(2)-receptor antagonists or proton-pump inhibitors is superior to placebo in treatment of FD, but those patients with meal-related symptoms are least likely to respond. Helicobacter pylori eradication in FD benefits a minority of cases but is worthwhile, as response may be maintained. There is increasing evidence that some prokinetics may be superior to placebo in treatment of FD, but probably only a minority respond; those with meal-related symptoms may have the best response. Antidepressant therapy may have a place in management of difficult cases, but adequate randomized controlled trials are unavailable.

A second-order simulation model of the cost-effectiveness of managing dyspepsia in the United States

BACKGROUND

The "gold-standard'' evidence of effectiveness for a clinical practice guideline is the randomized controlled trial (RCT), although RCTs have a limited ability to explore potential management strategies for a chronic disease where these interact over time. Modeling can be used to fill this gap, and models have become increasingly complex, with both dynamic sampling and representation of second-order uncertainty to provide more precise estimates. However, both simulation modeling and probabilistic sensitivity analysis are rarely used together. The objective of this study was to explore uncertainty in controversial areas of the 2005 American Gastroenterology Association position statement on the management of dyspepsia.

METHODS

Individual sampling model, incorporating a second-order probabilistic sensitivity analysis.

POPULATION

US adult patients presenting in primary care with dyspepsia. Interventions compared: empirical acid suppression, test and treat for Helicobacter pylori, initial endoscopy, acid suppression then endoscopy, test and treat then proton pump inhibitor (PPI) then endoscopy.

OUTCOMES

Cost-effectiveness, quality-adjusted life years, and costs in US dollars from a societal perspective, measured over a 5-year period.

DATA SOURCES

mainly Cochrane meta-analyses.

RESULTS

Endoscopy was dominated at all ages by other strategies. PPI therapy was the most cost-effective strategy in 30-year-olds with a low prevalence of H. pylori. In 60-year-olds, H. pylori test and treat was the most cost-effective option.

CONCLUSIONS

Acid suppression alone was more cost-effective than either endoscopy or H. pylori test and treat in younger dyspepsia patients with a low prevalence of infection.

The cost-effectiveness and budget impact of competing therapies in hepatic encephalopathy - a decision analysis

BACKGROUND

Treatment options for hepatic encephalopathy have disparate risks and benefits. Non-absorbable disaccharides and neomycin are limited by uncertain efficacy and common dose-limiting side effects. In contrast, rifaximin is safe and effective in hepatic encephalopathy, but is more expensive.

METHODS

We conducted a decision analysis to calculate the cost-effectiveness of six strategies in hepatic encephalopathy: (i) no hepatic encephalopathy treatment, (ii) lactulose monotherapy, (iii) lactitol monotherapy, (iv) neomycin monotherapy, (v) rifaximin monotherapy and (vi) up-front lactulose with crossover to rifaximin if poor response or intolerance of lactulose ('rifaximin salvage'). The primary outcome was cost per quality-adjusted life-year gained.

RESULTS

Under base-case conditions, 'do nothing' was least effective and rifaximin salvage was most effective. Lactulose monotherapy was least expensive, and rifaximin monotherapy was most expensive. When balancing cost and effectiveness, lactulose monotherapy and rifaximin salvage dominated alternative strategies. Compared to lactulose monotherapy, rifaximin salvage cost an incremental US$2315 per quality-adjusted life-year-gained. The cost of rifaximin had to fall below US$1.03/tab in order for rifaximin monotherapy to dominate lactulose monotherapy.

CONCLUSIONS

Rifaximin monotherapy is not cost-effective in the treatment of chronic hepatic encephalopathy at current average wholesale prices. However, a hybrid salvage strategy, reserving rifaximin for lactulose-refractory patients, may be highly cost-effective.

The budget impact of endoscopic screening for esophageal varices in cirrhosis

BACKGROUND

The cost-effectiveness of screening for esophageal varices in cirrhosis remains uncertain. Previous analyses found that screening with upper endoscopy (EGD) may not be cost effective versus empiric beta-blocker (BB) therapy. However, these models were conducted before advances in variceal screening, including capsule endoscopy (CE), and they did not measure the budget impact (vs cost-effectiveness) of variceal screening.

OBJECTIVE

To compare the managed care budget impact of variceal screening strategies.

DESIGN

Budget impact model.

SETTING

Hypothetical managed care organization with 1 million covered lives.

PATIENTS

Patients with compensated cirrhosis.

INTERVENTIONS

Compared 5 strategies: (1) empiric BB, (2) screening EGD followed by BB if varices present (EGD --> BB), (3) EGD followed by endoscopic band ligation if varices present (EGD --> EBL), (4) CE followed by BB if varices present (CE --> BB), and (5) CE followed by EBL if varices present (CE --> EBL).

MAIN OUTCOME MEASUREMENT

Per-member per-month cost.

RESULTS

BB was the least expensive, and CE --> EBL was the most expensive. Substituting CE --> BB in lieu of BB cost each member an additional $0.20 per month to subsidize. Compared with CE --> BB, both EGD-based strategies were more expensive. However, CE was not viable in managed care organizations capable of reducing the cost of endoscopy below $410, unless the cost of CE was reduced in lockstep.

LIMITATIONS

Data on CE remain limited.

CONCLUSIONS

Screening for varices may have an acceptable budget impact but is highly sensitive to local costs of EGD and CE. In managed care organizations willing to subsidize EBL for variceal prophylaxis, it is inefficient to screen with CE compared with EGD.

Randomized-controlled trial of esomeprazole in functional dyspepsia patients with epigastric pain or burning: does a 1-week trial of acid suppression predict symptom response?

BACKGROUND

Early identification of true responders to acid suppression in functional dyspepsia patients with symptoms of epigastric pain or burning may enable clinicians to optimally tailor treatment.

AIM

To evaluate whether a 1-w acid suppression trial is useful for identifying true responders in this population.

METHODS

Patients (18-70 years) were randomized to either esomeprazole 40 mg q.d.s., b.d. or placebo for 1w, and then esomeprazole 40 mg q.d.s. or placebo for 7w. Epigastric pain and/or burning were recorded on a 4-point scale (0 = none, 3 = severe). Trial-week response was defined as symptom score sum < or = 1 on last 3d of therapy; response at 8w was symptom score sum < or = 1 over preceding 7d.

RESULTS

1-w response rates were 33% (199 of 597), 29% (188 of 629) and 23% (71 of 315) with esomeprazole q.d.s., esomeprazole b.d. and placebo, respectively (P = 0.002 for esomeprazole groups vs. placebo). At 8w, trial week sensitivity and specificity were 46% and 80%, respectively, for esomeprazole (40 or 80 mg), and 33% and 87%, respectively, for placebo. The positive and negative predictive values for esomeprazole were 60% and 69%.

CONCLUSION

Response to a 1-w acid suppression trial is of limited use for predicting symptom response at 8w in patients with unexplained epigastric pain or burning.

Functional Dyspepsia: A New Rome III Paradigm

Functional dyspepsia (FD) is a condition commonly seen in gastroenterological practice. With the introduction of Rome III criteria in 2006, a new approach for categorizing patients has been recommended. The diagnostic criteria suggest that meal-related and pain-predominant symptom groupings that presumably have distinct pathophysiologic mechanisms and potentially different therapeutic targets exist. The new classification is in the early stages of testing; in the meantime, the umbrella term of FD should continue to be utilized in clinical practice. Treatment of FD remains a major challenge. Unfortunately, most of the agents used in practice have limited or no evidence of efficacy, and the results typically are short-lived once therapy is ceased. Appropriate therapy currently is based on a consideration of putative pathophysiologic mechanisms. Testing for and eradicating Helicobacter pylori is a first-line strategy irrespective of the symptom pattern. In patients who have epigastric pain, antisecretory agents are recommended. Antacids, bismuth, and sucralfate seem to be no better than placebo. For meal-related symptoms such as postprandial fullness or early satiety, prokinetics may confer some benefit. However, few choices are available, and the efficacy for those drugs on the market is limited at best. Antidepressants are of uncertain efficacy but are widely used. Psychological therapies seem promising and may confer benefits on both pain and meal-related symptoms. Efficacy of complementary medicines has been suggested in controlled trials, but more data are needed. Emerging treatments include gastric fundus relaxors and visceral analgesics, although their application in FD is still in the preliminary stages.

Gastric motor disorders

Gastric motor disorders constitute an important part of clinical gastroenterological practice. Normal gastric motor function includes gastric accommodation which provides a reservoir during meal ingestion, gastric emptying at a rate that matches small bowel absorptive function and interdigestive motility that eliminates indigestible particles. Disorders of gastric motor function include impaired accommodation, gastroparesis and dumping syndrome. This review summarises current knowledge on the pathophysiology, diagnostic approach and treatment for these disorders.

Initial treatment with lansoprazole in young dyspeptic patients with negative urea breath test result: a randomized controlled trial with 12-month follow-up

INTRODUCTION

Although empirical antisecretory drug therapy is recommended to young dyspeptic patients without alarming features, the effectiveness of this approach remains undetermined. We evaluated the long-term effects of an initial 12-wk course of lansoprazole in young dyspeptic patients without Helicobacter pylori (H. pylori) infection.

METHODS

Patients who were less than 45 yr and presented with at least 3 months of dyspepsia in the absence of alarming features were eligible. They were offered (13)C-urea breath test (UBT) to determine H. pylori status and all symptomatic patients with negative UBT were randomized to receive lansoprazole 30 mg daily or placebo for 12 wk. Those who had previous endoscopy or positive UBT were excluded. Primary end point was the proportion of patients with treatment failure, defined as worsening of global dyspeptic symptom, while on study medication. Patients were followed up for 26 wk for global dyspeptic symptom as determined by 7-point Likert scale. Quality-of-life assessment (SF-36), need of endoscopy, and utilization of other health-care services were monitored for 52 wk.

RESULTS

A total of 157 dyspeptic patients were randomized. At the end of 12-wk treatment, the proportion of patients with treatment failure was similar in the lansoprazole (33.3%) and placebo (30.3%) groups (P= 0.74). Patients' global assessment of their dyspeptic symptom was comparable at all time points measured. There was also no significant difference in the SF-36 mental and physical summary scales. At the end of 52 wk, there was no difference in the proportion of patients who underwent endoscopy, had additional medical consultations, or used other nonstudy medications between the two groups.

CONCLUSION

Lansoprazole is not effective in the initial management of young dyspeptic patients without H. pylori infection.

Influence of genetics on irritable bowel syndrome, gastro-oesophageal reflux and dyspepsia: a twin study

BACKGROUND

A genetic contribution has been proposed for irritable bowel syndrome (IBS) and gastro-oesophageal reflux disease (GERD), but is controversial. No twin data exist for dyspepsia.

AIM

To determine the relative contribution of genetic factors in GERD, dyspepsia (upper abdominal pain) and IBS.

METHODS

A total of 986 twin pairs (from initial mail-out response 51%). Both members completed validated symptom and psychological questionnaires; 481 monozygotic pairs [mean (s.d.) age 53 +/- 5.8 years] and 505 dizygotic pairs (mean age 54 +/- 5.6 years).

RESULTS

Prevalence of IBS, dyspepsia and GERD was 12%, 10% and 20%, respectively. Polychoric correlation for monozygotic twins for IBS (0.47) and GERD (0.44) were both substantially larger than those for dizygotic twins (0.17 and -0.37, respectively). Polychoric correlation was slightly lower in monozygotic than dizygotic twins for dyspepsia. Genetic modelling confirmed the independent additive genetic effects in GERD and IBS but not dyspepsia. Estimates of genetic variance were 22% for IBS, 13% for GERD and 0% for dyspepsia, but adjusting for anxiety and depression removed the statistical significance for IBS and GERD.

CONCLUSIONS

There is a genetic contribution to GERD and IBS but not dyspepsia; this may be mediated by the hereditability of anxiety and depression.

STW 5, a phytopharmacon for patients with functional dyspepsia: results of a multicenter, placebo-controlled double-blind study

BACKGROUND

Functional dyspepsia (FD) constitutes a complex picture with a variety of epigastric symptoms. No standard therapy is currently available for FD.

OBJECTIVE

This multicenter, placebo-controlled, double-blind study evaluated the efficacy and tolerability of the herbal drug STW 5, mainly comprising a fresh plant extract from Iberis amara.

METHODS

Patients with FD were included. Gastrointestinal endoscopy, H. pylori-status, and a 7-day run-in phase were required. A total of 315 patients were treated with 3 x 20 drops/day of either STW 5 or placebo. Symptom assessment: day 0, 2, 4, and 8 wk of treatment. The principal outcome criterion was the change in a validated Gastrointestinal Symptom Score (GIS). Symptom severity was rated using the Likert scale.

RESULTS

A total of 315 patients remained in the safety population. Of them, 158 were treated with STW 5 and 157 with placebo. The intention-to-treat population comprised 308 patients. Dropout number was similar in both groups. GIS showed improvement during the treatment period. The STW 5 group improved 6.9+/-4.8 points up to day 56, placebo group by 5.9+/-4.3 (P<0.05). H. pylori did not influence the results. Drug tolerability and safety were similar in both groups.

CONCLUSION

This placebo-controlled study with an 8-wk treatment period documents the efficacy of STW 5 in FD.

Symptom overlap in patients with upper gastrointestinal complaints in the Canadian confirmatory acid suppression test (CAST) study: further psychometric validation of the reflux disease questionnaire

BACKGROUND

The reflux disease questionnaire (RDQ) is a short, patient-completed instrument.

AIMS

To investigate the psychometric characteristics of the RDQ in patients with heartburn-predominant (HB) and non-heartburn predominant (NHB) dyspepsia.

METHODS

HB (n = 388) and NHB (n = 733) patients were randomized to esomeprazole 40 mg daily or twice daily for 1 week, followed by 3 weeks of esomeprazole 40 mg daily.

RESULTS

High factor loadings (0.78-0.86) supported the 'regurgitation' dimension of the RDQ. Overlapping factor loadings in the 'heartburn' and 'dyspepsia' dimensions suggested symptom overlap. All dimensions demonstrated high internal consistency (Cronbach's alpha: 0.79-0.90). Intra-class correlation coefficients over 4 weeks were good (0.66-0.85). The RDQ showed good responsiveness over 4 weeks of treatment, with high effect sizes (> or =0.80). Moderate or large symptom improvements were reported by 90% and 77% of HB and NHB patients, respectively, following treatment. Patients who responded to acid suppression also experienced symptom benefits in all RDQ dimensions.

CONCLUSIONS

The RDQ is reliable, valid and responsive to change in HB and NHB patients. The symptom overlap is important but need not play a major role in determining treatment strategy as both patient groups benefited from proton pump inhibitor treatment.

Proton pump inhibitors: effective first-line treatment for management of dyspepsia

The aim of this study was to evaluate the reasons for trial exclusion among dyspeptic patients and estimate the proportion that may have benefited from proton pump inhibitor (PPI) therapy. Stringent inclusion criteria for enrollment in two multicenter functional dyspepsia trials included dyspepsia (predominant persistent/recurrent upper abdominal discomfort [UAD] during the prior 3 months) of at least moderate intensity during > or =30% of days during the prior 2 to 3 weeks. Exclusion criteria were mild/infrequent UAD; heartburn and UAD of equal frequency; predominant heartburn with UAD; endoscopic evidence of erosive esophagitis or Barrett's or gastric and/or duodenal erosions (>5) or ulcers; irritable bowel syndrome (IBS); other gastrointestinal diagnoses; or other "non-categorized" disorders. Of 2,588 screened patients, 1,667 were excluded. Excluded patients by category had mild/infrequent UAD (12.5%, n=324), heartburn and UAD of equal frequency (1.1%, n=29), predominant heartburn with UAD (11.6%, n=300), endoscopic evidence of erosive esophagitis or Barrett's (6.2%, n=160), gastric and/or duodenal erosions (1.4%, n=36), gastric and/or duodenal ulcers (2.0%, n=53), IBS (7%, n=180), "other" gastrointestinal diagnoses (2.8%, n=73), or other "non-categorized" disorders (19.8%, n=512). Fifty-four percent of patients (902/1,667) had symptoms/diagnoses that would be expected to improve with PPI therapy. Individuals with IBS, "other," or "non-categorized" disorders were considered to have symptoms unlikely to respond to PPI treatment. Empiric PPI treatment would be expected to provide symptom relief to the majority of dyspepsia sufferer who present in clinical practice. PPIs represent the best currently available therapy for acid-related disorders and should be considered the first-line management approach in patients with uninvestigated dyspepsia.

The health economics of Helicobacter pylori infection

Economic considerations are becoming increasingly important as health care becomes more expensive. Evidence for effectiveness is usually gained from randomised controlled trials (RCTs) but often there is insufficient evidence of the costs of alternative strategies in trials. Often, therefore, economic models are needed to extrapolate data from a variety of sources to give an indication of which strategy is cost effective. Helicobacter pylori (H. pylori) testing and treating in a wide variety of upper gastrointestinal diseases is a good example of the application of economic analyses to health care interventions. H. pylori eradication in peptic ulcer disease is very effective with systematic reviews giving a number needed to treat of around two compared to no therapy. RCTs have also suggested that treating H. pylori is also more effective and less expensive than continuous H(2) receptor antagonist therapy and is therefore the dominant strategy in treating peptic ulcer disease. The impact of H. pylori eradication in infected patients with functional dyspepsia is less dramatic, with systematic reviews suggesting a number needed to treat of 14. Economic models suggest that in Europe H. pylori eradication is cost-effective compared to offering no treatment (e.g. in the UK we can be 95% certain this approach is cost effective if you are willing to pay $51/month free from dyspepsia). In the USA it is less certain that this is a cost-effective approach due to the higher cost of eradication therapy. H. pylori test and treat has been proposed as an alternative to early endoscopy in patients with uninvestigated dyspepsia. We have conducted an individual patient data meta-analysis of five RCTs that has addressed the cost effectiveness of this approach. Endoscopy was slightly more effective than H. pylori test and treat at relieving dyspepsia at one year but was not cost-effective as it cost $9000/dyspepsia cure at one year. Population H. pylori test and treat has been proposed as a strategy to prevent noncardia gastric cancer. RCTs have suggested this approach may be cost saving but more data are needed on whether H. pylori eradication will reduce gastric cancer mortality before this strategy can be recommended.

Effects of proton-pump inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials

BACKGROUND & AIMS

The aim of this study was to assess systematically the efficacy of proton pump inhibitors (PPIs) in the treatment of functional dyspepsia compared with placebo and to determine if any difference in the response exists between symptom subgroups of functional dyspepsia.

METHODS

A literature search was performed through September 2005 in PubMed, Medline, Embase, CINAHL, and Cochrane databases to include randomized, double-blind, placebo-controlled trials evaluating the efficacy of PPIs for the treatment of functional dyspepsia. Relative risk (RR) and relative risk reduction (RRR) and 95% confidence intervals (CI) were calculated under a random-effects model.

RESULTS

Seven studies with a total of 3725 patients were identified. PPIs were found to be more effective than placebo for reducing symptoms in patients with functional dyspepsia (RRR, 10.3%; 95% CI, 2.7%-17.3%). The estimated number needed to treat is 14.6 (95% CI, 8.7-57.1). When stratified analyses were performed, a significant difference in the efficacy was observed only in patients with ulcer-like (RRR, 12.8%; 95% CI, 7.2%-18.1%) and reflux-like dyspepsia (RRR, 19.7%; 95% CI, 1.8%-34.3%), but not in those with dysmotility-like (RRR, 5.1%; 95% CI, -10.9% to 18.7%) and unspecified dyspepsia (RRR, -8.0%; 95% CI, -23.7% to 5.6%). The effect of H pylori on the efficacy of PPIs remains unclear. Significant heterogeneity among studies was found for the overall analysis, dysmotility-like dyspepsia, H pylori-negative subgroup, and different dose subgroups.

CONCLUSIONS

PPIs are more effective than placebo for the management of patients with ulcer-like and reflux-like functional dyspepsia.

How to manage the difficult-to-treat dyspeptic patient

The main causes of dyspepsia are unexplained gastroduodenal symptoms (i.e. functional dyspepsia), peptic ulcer disease, reflux disease and, rarely, malignancy. A careful clinical evaluation and upper endoscopy will exclude most of the major causes of dyspepsia. The absence of alarm features is reassuring. The yield of other diagnostic tests in this clinical situation is low, and repeat endoscopy is unlikely to be cost-effective. By definition, the difficult-to-treat patient with functional dyspepsia has already had Helicobacter pylori infection excluded or eradicated, has failed to respond to an adequate trial of acid-suppression therapy that used appropriate doses and, therefore, seeks other solutions. It is likely that patients who have failed to respond to previous trials of a PPI will not experience therapeutic gains with high-dose PPI therapy. A major gastroduodenal motor disorder should be suspected if there is severe early satiation (inability to finish a normal-sized meal), postprandial fullness, or persistent nausea and vomiting; here, an assessment of gastric emptying or gastric accommodation can be considered, to tailor therapy. Antidepressants (especially low-dose tricyclic agents) and psychological therapies can be useful. Creation of a logical management plan that includes patient education and support remains key.

Esomeprazole 40 mg once a day in patients with functional dyspepsia: the randomized, placebo-controlled "ENTER" trial

OBJECTIVE

The etiologies of functional dyspepsia (FD) are unclear, but in some studies, treatment with a proton pump inhibitor has been beneficial. The objective of this study was to evaluate the efficacy of esomeprazole 40 mg once a day compared to placebo in achieving symptom relief in primary care patients with FD.

METHODS

This was a randomized, placebo-controlled trial in adult FD patients, who had at least moderate severity of symptoms, defined as a score of > or =4 on a 7-point Global Overall Symptom (GOS) scale. Patients were excluded if they had predominant symptoms of heartburn or regurgitation; after a normal baseline endoscopy, patients were randomized to esomeprazole 40 mg once daily or placebo for 8 wk. The primary outcome measure was symptom relief (GOS < or =2) at 8 wk.

RESULTS

Of the 502 enrolled patients, 224 were randomized. The main reasons for exclusion were abnormal endoscopic findings, especially esophagitis. A significantly greater proportion of patients in the esomeprazole group achieved symptom relief at 4 but not at 8 wk compared to placebo: 4 wk esomeprazole 50.5% versus placebo 32.2%, p= 0.009; 8 wk esomeprazole 55.1% versus placebo 46.1%, p= 0.16. A similar relationship at 4 and 8 wk was seen for symptom resolution (GOS = 1) and improvement (DeltaGOS > or =2).

CONCLUSION

For the primary outcome measure of symptom relief at 8 wk, there was no statistically significant difference between esomeprazole 40 mg once a day and placebo. However, at 4 wk, esomeprazole was significantly more effective than placebo for symptom relief. The difference in therapeutic gain between 4 and 8 wk was largely due to a higher placebo response rate at 8 wk.

Review article: current and emerging therapies for functional dyspepsia

Functional dyspepsia represents a heterogeneous group of gastrointestinal disorders marked by the presence of upper abdominal pain or discomfort. Although its precise definition has evolved over the last several decades, this disorder remains shrouded in controversy. The symptoms of functional dyspepsia may overlap with those of other functional bowel disorders including irritable bowel syndrome and non-erosive reflux disease. There may be coexistent psychological distress or disease complicating its presentation and response to therapy. Given the prevalence and chronicity of functional dyspepsia, it remains a great burden to society. Suspected physiological mechanisms underlying functional dyspepsia include altered motility, altered visceral sensation, inflammation, nervous system dysregulation and psychological distress. Yet the exact pathophysiological mechanisms that cause symptoms in an individual patient remain difficult to delineate. Numerous treatment modalities have been employed including dietary modifications, pharmacological agents directed at various targets within the gastrointestinal tract and central nervous system, psychological therapies and more recently, complementary and alternative treatments. Unfortunately, to date, all of these therapies have yielded only marginal results. A variety of emerging therapies are being developed for functional dyspepsia. Most of these therapies are intended to normalize pain perception and gastrointestinal motor and reflex function in this group of patients.

Therapeutic strategies for functional dyspepsia and the introduction of the Rome III classification

Although placebo response rates in clinical trials for functional dyspepsia (FD) are more than 30%, a recent meta-analysis based on randomized controlled trials (RCTs) showed that antisecretory drugs were more or less superior to placebos. On the other hand, large-scale RCTs on the efficacy of treatment with prokinetics on FD are still needed. Indications for antibiotic eradication therapy for Helicobacter pylori-positive FD are still controversial, but there seems to be a small but significant therapeutic gain achieved with H. pylori eradication. Since preprandial and postprandial symptomatic disturbances are very important targets for FD treatment, ghrelin, a novel appetite-promoting gastrointestinal peptide that also promotes gastric motility or basal acid secretion can be expected to be a therapeutic target. In the recently published Rome III classification, FD is redefined for patients with symptoms thought to originate from the gastroduodenal region, specifically epigastric pain or burning, postprandial fullness, or early satiation, and it is divided into the subcategories postprandial distress syndrome and epigastric pain syndrome. These new criteria are of value in clinical practice, for epidemiological, pathophysiological, and clinical research, and for the development of new therapeutic strategies.

Subtypes of functional dyspepsia

Functional dyspepsia is a common clinical condition characterised by chronic or recurrent upper abdominal pain or discomfort commonly associated with a variety of associated gastrointestinal symptoms and a normal endoscopy. To standardise research-based approaches, an initial categorisation of into sub groups was agreed to, based on clusters of symptoms. However the early expectation that these subgroups would be associated with distinct pathophysiologies amenable to specific therapy has not been realised. A classification based on the most troublesome symptom has been suggested but the utility of this is also unclear. More recent data suggest that some of the pathophysiologic dysfunctions may be associated with specific symptoms and so provide a better tool for grouping patients. But this approach remains incomplete as current insights into the pathogenesis are still too limited for this to be satisfactory. In conclusion, no classification provides for an adequate treatment-based approach to the syndrome of functional dyspepsia. As a consequence treatment remains largely empiric.

Functional gastroduodenal disorders

A numerically important group of patients with functional gastrointestinal disorders have chronic symptoms that can be attributed to the gastroduodenal region. Based on the consensus opinion of an international panel of clinical investigators who reviewed the available evidence, a classification of the functional gastroduodenal disorders is proposed. Four categories of functional gastroduodenal disorders are distinguished. The first category, functional dyspepsia, groups patients with symptoms thought to originate from the gastroduodenal region, specifically epigastric pain or burning, postprandial fullness, or early satiation. Based on recent evidence and clinical experience, a subgroup classification is proposed for postprandial distress syndrome (early satiation or postprandial fullness) and epigastric pain syndrome (pain or burning in the epigastrium). The second category, belching disorders, comprises aerophagia (troublesome repetitive belching with observed excessive air swallowing) and unspecified belching (no evidence of excessive air swallowing). The third category, nausea and vomiting disorders, comprises chronic idiopathic nausea (frequent bothersome nausea without vomiting), functional vomiting (recurrent vomiting in the absence of self-induced vomiting, or underlying eating disorders, metabolic disorders, drug intake, or psychiatric or central nervous system disorders), and cyclic vomiting syndrome (stereotypical episodes of vomiting with vomiting-free intervals). The rumination syndrome is a fourth category of functional gastroduodenal disorder characterized by effortless regurgitation of recently ingested food into the mouth followed by rechewing and reswallowing or expulsion. The proposed classification requires further research and careful validation but the criteria should be of value for clinical practice; for epidemiological, pathophysiological, and clinical management studies; and for drug development.

Predictors of the placebo response in functional dyspepsia

BACKGROUND

Trials in functional dyspepsia report placebo response rates of 30% to 40%.

AIM

We aimed to identify predictors of the placebo response.

METHODS

Patients from primary, secondary and tertiary practices with functional dyspepsia defined by Rome II criteria were enrolled into one of four clinical trials; 220 patients were randomized to receive placebo. Scintigraphic assessment of gastric emptying at baseline was repeated at the end of the treatment in those with delayed emptying. After a 2 week run-in period, patients were followed for 8 weeks on placebo. Response was assessed on a weekly basis and a responder was defined as satisfactory relief of meal-related symptoms on at least 50% of weeks.

RESULTS

The mean age was 44 years (range 18-82) and 74% were female; 76 (35%) were placebo responders. The predominant symptom was an unstable measure over the trial. Independent predictors of a lower placebo response were lower body mass index and a more consistent predominant symptom pattern (both P < 0.05). No association was seen with age, gender, centre type, baseline symptom score, baseline or change in gastric emptying, or baseline quality of life.

CONCLUSION

In functional dyspepsia, a consistent predominant symptom pattern and lower body mass index may be associated with a lower placebo response rate.

A placebo-controlled trial of itopride in functional dyspepsia

BACKGROUND

The treatment of patients with functional dyspepsia remains unsatisfactory. We assessed the efficacy of itopride, a dopamine D2 antagonist with anti-acetylcholinesterase [corrected] effects, in patients with functional dyspepsia.

METHODS

Patients with functional dyspepsia were randomly assigned to receive either itopride (50, 100, or 200 mg three times daily) or placebo. After eight weeks of treatment, three primary efficacy end points were analyzed: the change from baseline in the severity of symptoms of functional dyspepsia (as assessed by the Leeds Dyspepsia Questionnaire), patients' global assessment of efficacy (the proportion of patients without symptoms or with marked improvement), and the severity of pain or fullness as rated on a five-grade scale.

RESULTS

We randomly assigned 554 patients; 523 had outcome data and could be included in the analyses. After eight weeks, 41 percent of the patients receiving placebo were symptom-free or had marked improvement, as compared with 57 percent, 59 percent, and 64 percent receiving itopride at a dose of 50, 100, or 200 mg three times daily, respectively (P<0.05 for all comparisons between placebo and itopride). Although the symptom score improved significantly in all four groups, an overall analysis revealed that itopride was significantly superior to placebo, with the greatest symptom-score improvement in the 100- and 200-mg groups (-6.24 and -6.27, vs. -4.50 in the placebo group; P=0.05). Analysis of the combined end point of pain and fullness showed that itopride yielded a greater rate of response than placebo (73 percent vs. 63 percent, P=0.04).

CONCLUSIONS

Itopride significantly improves symptoms in patients with functional dyspepsia. (ClinicalTrials.gov number, NCT00272103.).

Validation of a 7-point Global Overall Symptom scale to measure the severity of dyspepsia symptoms in clinical trials

BACKGROUND

Currently there is no consensus on the optimal method to measure the severity of dyspepsia symptoms in clinical trials.

AIM

To validate the 7-point Global Overall Symptom scale.

METHODS

The Global Overall Symptom scale uses a 7-point Likert scale ranging from 1 = no problem to 7 = a very severe problem. Validation was performed in two randomized-controlled trials (n = 1121 and 512). Construct validity: Global Overall Symptom was compared with the Quality of Life in Reflux And Dyspepsia, Gastrointestinal Symptom Rating Scale, Reflux Disease Questionnaire and 10 specific symptoms using Spearman correlation coefficients. Test-retest reliability: The Intraclass Correlation Coefficient was calculated for patients with stable dyspepsia defined by no change in Overall Treatment Effect score over two visits. Responsiveness: effect size and standardized response mean were also calculated.

RESULTS

Construct validity: Change in Global Overall Symptom score correlated significantly with Quality of Life for Reflux And Dyspepsia, Gastrointestinal Symptom Rating Scale, Reflux Disease Questionnaire and specific symptoms (all P < 0.0002). Reliability: The Intraclass Correlation Coefficient was 0.62 (n = 205) and 0.42 (n = 270). Responsiveness: There was a positive correlation between change in Global Overall Symptom and change in symptom severity. The effect size and standardized response mean were 1.1 and 2.1, respectively.

CONCLUSION

The Global Overall Symptom scale is a simple, valid outcome measure for dyspepsia treatment trials.