Dyspepsia is such a common and important symptom that most GPs will already be working under some sort of guidance, often from their primary care organisation or perhaps hospital colleagues. The recommendations in the recently published NICE guideline on dyspepsia should supersede any such guidance, and should also help to streamline and coordinate many local policies.
Key messages from the guideline are clear and stand out from the quick reference guide, which busy GPs will find useful. The guideline includes a review of drugs that are implicated in causing dyspepsia symptoms – useful for those of us whose knowledge of pharmacology is rusty – and a list of ‘alarm signs’; these are signs and symptoms, such as weight loss and haematemesis, that require urgent endoscopy. In the absence of alarm signs, even in patients over 55 years urgent referral for endoscopic investigation is not necessary.
Helicobacter pylori testing is recommended in almost all cases except for gastro-oesophageal reflux disease, and it has only modest benefit in non-ulcer dyspepsia and undiagnosed dyspepsia. A 13C breath test is the favoured method of testing for H. pylori.
The guideline’s separate algorithms for each cause of dyspepsia may appear a little confusing. Differences relate mainly to duration of antacid therapy, the use of alternatives to proton pump inhibitors (PPIs) and the point at which H. pylori testing should be considered. Given the thrust of this guideline, that without alarm signs patients do not need urgent investigation, most of our patients will be taken through the ‘uninvestigated dyspepsia’ pathway.
Previously, it was my practice to give patients with mild dyspepsia simple antacids and H2 receptor antagonists initially, mainly with an eye to cost. The guideline, however, recommends PPIs as first-line therapy, and with omeprazole off patent and lansoprazole soon to join it, using these drugs as initial therapy should have little adverse impact on prescribing budgets.
The recommendation of annual reviews for patients with dyspepsia is welcome, and this task may be best carried out by the practice nurse. Practices will need to review long-term PPI prescribing and ensure patients understand that they should use the minimum effective dose and, as far as possible, only when required.
This guideline should form the basis of discussions between primary and secondary care in each locality. While the guideline should reduce unnecessary endoscopies, when it is required endoscopy should be timely. H. pylori testing will become more routine; urea breath test kits are currently available on prescription and will be the preferred method for most clinicians unless laboratory-based serology has been locally validated. Agreement will also need to be reached about joint care pathways for patients seen in secondary care and who need continuing follow up.
There is a section for pharmacists, who are often approached by patients for advice, and as with all NICE guidelines, there is a version for patients, which is particularly useful because self-medication is common in dyspepsia.
GPs should come away from reading this guideline with a clearer picture of the need for investigation and how to manage patients with dyspepsia, even if the subtle differences in treatment of diagnosed patients remain a little obscure.
NICE Clinical Guideline 17. Dyspepsia – management of dyspepsia in adults in primary care can be downloaded from the NICE website: www.nice.org.uk