Over-the-counter histamine H2-receptor antagonists. How will they affect the treatment of acid-related diseases?

Review article: acid suppression in the management of gastro-oesophageal reflux disease--an appraisal of treatment options in primary care

Gastro-oesophageal reflux disease (GERD) is one of the most common conditions presenting to the primary care physician. Despite progress in understanding and treatment of the disease, strategies for capitalizing on these advances are less well developed. In many practices, H2-receptor antagonists still remain the most widely prescribed treatment for GERD, despite the availability of the more effective acid-suppressant proton pump inhibitors. This review examines the relative efficacies of acid-suppressant drugs in minimizing oesophageal acid exposure and outlines the evidence for the superiority of proton pump inhibitors over standard-dose H(2)-antagonists in symptom relief, erosion healing and prevention of relapse in GERD. Current prescribing patterns and considerations for the general practitioner are also examined. The availability and impact of over-the-counter H(2)-antagonists on the treatment of GERD and their relative cost-effectiveness vs. proton pump inhibitors are also addressed. A hierarchy of drug efficacy (full-dose proton pump inhibitor > half-dose proton pump inhibitor > high-dose H(2)-antagonist > standard-dose H(2)-antagonist or prokinetic) applies in principle to all GERD patients, (with or without oesophagitis). The most effective initial therapy for GERD is also likely to be the most cost-effective one, if treatment failure leads to higher utilization of medical resources. The application of these recommendations to the management of non-endoscoped GERD, endoscopy-negative GERD and low-grade oesophagitis as well as higher grade oesophagitis is also reviewed.

Strategies for reducing the prescribing of proton pump inhibitors (PPIs): patient self-regulation of treatment may be an under-exploited resource

Escalating costs of proton pump inhibitor (PPI) prescribing are a source of increasing concern. To reduce costs, GPs in the UK have been coming under pressure to restrict PPI prescribing in primary care, e.g. by raising the prescribing threshold for new patients, and encouraging established patients to accept a reduced dose, if not stop taking PPIs altogether. The need to reduce prescribing costs impacts on patients by redefining, i.e. reducing, the boundaries of clinical need for which PPI prescribing is deemed appropriate. This may be rationalised by the assumptions that much existing prescribing is inappropriate, is applied to relatively minor and trivial afflictions, and that patients put pressure on their doctors to initiate prescribing of PPIs, after which they are very reluctant to give them up. The research involved extended interviews to elicit GP and patient views and experience of PPI prescribing. A particular focus was a comparison of the views of patients and GPs, and the understanding and articulation of the patient perspective on PPIs, which has been largely absent from the discussion to date. The research identified six distinct strategies used by GPs in their efforts to reduce PPI prescribing. Contrary to what GPs often assumed to be the case, patients were generally quite receptive to changes to their medication, provided they had the security of knowing that their original prescription would be restored if necessary. Most doctors assessed their rationing strategies as having some impact, but acknowledged the difficulties in achieving a significant and sustained reduction in PPIs. In the study sample nearly half of the patients who had experienced a prescribing switch or step down had drifted back to their former brand, and, especially, higher dose. However, far from being overly and unreflectively dependent on PPIs, patients were often keen to reduce their medicine taking to a minimum. A number of respondents had taken the initiative in experimenting to find the lowest effective dose of PPIs required to control their symptoms. GPs varied in their attitudes to this form of treatment self-management, but less than half actively encouraged patients to regulate their treatment in this way. Our findings suggest that there is considerable scope for encouraging patients to self-regulate with PPIs, and that many patients would be willing to do this if the practice was sanctioned by their doctors. The anticipated benefits of increased self-regulation include an overall reduction in PPI prescribing and associated costs, and an increase in patient autonomy and control which is in line with the concordance model of the ideal relationship between patients and doctors.

The effect of cimetidine on the pharmacodynamics of theophylline-induced seizures and ethanol hypnotic activity

Due to its availability as an over-the-counter drug, the use of cimetidine is increasing, thus adverse interactions with other commonly used agents may also increase. The aim of this study was to investigate whether acute administration of cimetidine could alter the pharmacodynamics of theophylline neurotoxicity and the hypnotic action of ethanol. To examine these questions, rats received a dose of 77 mg/kg cimetidine followed by a constant infusion of either theophylline (1.2 mg/min.) or ethanol (16.3 mg/min.) until the onset of the pharmacological end point, maximal seizure or loss of righting reflex, where samples of blood and brain were obtained and assayed for either theophylline or ethanol. We report that cimetidine in doses that may cause pharmacokinetic interactions did not affect the concentration-effect relationship of either the stimulating action of theophylline or the depressant activity of ethanol. These outcomes emphasize the relative safety which patients using cimetidine in self-medication rely on.

The rise and rise of proton pump inhibitor drugs: patients' perspectives

The prescribing of proton pump inhibitor (PPIs) drugs has increased by 456% in the past 4 yr, despite no evidence of increased morbidity for gastrointestinal conditions. There has been no full explanation for this dramatic increase. Doctors attribute the rapid and apparently unjustified increase in prescribing of this new and expensive drug to patients' demands and not to the extensive advertising campaign. This paper presents the findings from interviews with 20 patients who were taking PPIs. The results revealed that the prescribing of PPIs was mainly initiated in primary care, with little evidence of overt patient demand for PPIs, influenced by the media or social contacts. Patients' perceptions and beliefs about PPIs are explored and discussed. Patients modified the prescribed regimen to suit their perceived needs. Patients felt PPIs were more effective than other drugs they had tried previously and expressed their concerns about stopping PPIs, or changing to another drug. However, despite these reservations, the majority of patients interviewed said they would change if their general practitioner (GP) suggested it. PPIs led some patients to abandon, or not to attempt, lifestyle changes. The consequences of this and the implications of the continued prescribing of PPIs are discussed.

Policy analysis of the conversion of histamine2 antagonists to over-the-counter use

OBJECTIVES

The authors assess the costs associated with treatment of dyspepsia with histamine2 antagonists versus without availability of over-the-counter (OTC).

METHODS

A cost analysis was performed using a decision-analysis model. Patients with an initial episode of dyspepsia were studied. The model includes costs associated with consumption of OTC and prescription (Rx) medications for dyspepsia, physician visits and associated diagnostic testing, time spent for physician visits and diagnostic tests, and hospitalization costs.

RESULTS

The model is sensitive to the relative cost of histamine2 antagonists when purchased Rx or OTC, as well as to the efficacy of these drugs in relieving dyspeptic symptoms. For patients with nonulcer dyspepsia (the largest group of likely consumers), the model demonstrates a cost savings if the OTC cost of the medication is slightly less than one third the Rx cost. Costs are similar whether or not histamine2 antagonists are available OTC. If the symptom relief efficacies of histamine2 antagonists are equivalent whether purchased by prescription only or OTC, then the health-care expenditures for a typical patient with dyspepsia are $204 for OTC availability and $203 for Rx-only use. Viewing costs from the perspective of a managed-care organization, expenditures for an episode of dyspepsia are $149 regardless of whether or not histamine2 antagonists are available OTC. Restricting the analysis to patients with underlying nonulcer dyspepsia yields similar results. Variation of numerous assumptions and probabilities other than histamine antagonist cost and efficacy, including costs associated with physician visits and diagnostic tests, and the likelihood of seeking medical care, do not substantially affect the results of the model.

CONCLUSIONS

Health-care costs associated with initial treatment of dyspepsia are similar regardless of the availability of histamine2 antagonists OTC. This is due largely to the similar efficacy of these drugs compared with antacids and the predicted increase in diagnostic testing that may result if a patient visits a physician after failure to achieve symptom relief with OTC use of histamine2 antagonists.

A risk-benefit assessment of drugs used in the eradication of Helicobacter pylori infection

Helicobacter pylori is the cause of chronic active gastritis and predisposes to peptic ulcer disease (PUD). Furthermore, H. pylori is linked to the pathogenesis of gastric lymphoma and gastric cancer. However, treatment of this infection has proven difficult. In the last decade, many antimicrobial compounds have been studied extensively as monotherapy as well as in combination with bismuth or acid-suppressive drugs. The individual drugs and the most important eradication regimens are discussed with special regard to their risks. In the past, highly complex multidrug regimens, fear of adverse effects and frequent eradication failures have hampered the broad acceptance of H. pylori-eradication therapies. Recently, new 1-week, low-dose combination regimens of 2 antibacterials with a proton pump inhibitor have consistently achieved eradication rates of 90% and more with an acceptably low rate of adverse effects. One week's standard triple therapy [tripotassium dicitrato bismuthate (or bismuth salicylate plus metronidazole plus tetracycline or amoxicillin) has been shown to be highly effective and tolerated better in combination with a proton pump inhibitor. This regimen is, however, more complex and has more adverse effects. Therefore, it is not recommended as first-line therapy. Equipped with these therapies physicians can now be strongly encouraged to use H. pylori eradication as the therapy of choice for patients with PUD and even extend this treatment to other H. pylori-associated disease conditions.