PPIs are effective drugs for the treatment of gastro-esophageal reflux disease (GERD). Patients should always be prescribed the lowest dose of drug that manages their symptoms. Even though GERD is often a chronic condition, over time the disease may not require acid suppression and it is important that patients do not take drugs that are no longer necessary. For this reason patients should try stopping their acid suppressive therapy at least once per year. Patients with Barrett’s esophagus, Los Angeles Grade D esophagitis, and gastrointestinal bleeding would be exempt from this.
Cahir C, et al. Proton pump inhibitors: potential cost reductions by applying prescribing guidelines. BMC Health Serv Res. 2012 Nov 19;12:408. PMID: 23163956.
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Upper GI series are often requested for the investigation of upper gastrointestinal symptoms. This investigation has a significant proportion of false positive and false negative results compared with endoscopy, and studies have consistently found that this is not a cost-effective approach compared to other strategies of managing dyspepsia.
Makris N, et al. Cost-effectiveness of alternative approaches in the management of dyspepsia. Int J Technol Assess Health Care. 2003 Summer;19(3):446-64. PMID: 12962332.
Talley NJ, et al. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80. PMID: 16285971.Share on Facebook Share on Twitter
Endoscopy is an accurate test for diagnosing dyspepsia, but organic pathology that does not respond to acid suppression or Helicobacter pylori eradication therapy is rare under the age of 65. Most guidelines therefore recommend as the first line approach for managing dyspepsia either empirical proton pump inhibitor therapy or a non-invasive test for Helicobacter pylori and then offering therapy if the patient is positive. If the patient has alarm features such as progressive dysphagia, anemia or weight loss, endoscopy may be appropriate.
Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol 2017;112:988-1013. PMID: 28631728
Constipation is a common problem and systematic review data suggests this is not an accurate symptom in diagnosing organic disease. If the patient is also under the age of 50 and does not have a family history of colon cancer and there are no alarm features such as anemia or weight loss, then the risk of colorectal cancer is very low and the risks of colonoscopy usually outweigh the benefits in these patients.
Ford AC, et al. Diagnostic utility of alarm features for colorectal cancer: systematic review and meta-analysis. Gut. 2008 Nov;57(11):1545-53. PMID: 18676420.
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The risks of long term steroid therapy (therapy for more than 4 months and/or more than two courses in a year) outweigh any benefits in inflammatory bowel disease and should not be given to patients. Instead, they should be offered more effective maintenance therapy such as immunosuppression or biologic therapy that are safer and have more evidence for efficacy.
Talley NJ, et al. An evidence-based systematic review on medical therapies for inflammatory bowel disease. Am J Gastroenterol. 2011 Apr;106 Suppl 1:S2-25; quiz S26. PMID: 21472012.Share on Facebook Share on Twitter
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