Individuals, health care institutions and Alberta Blue Cross spend millions of dollars for the use and “abuse” of pills for indigestion, heartburn and the treatment of peptic ulcer disease. Is there a sensible way of using these pills?

Recently, this subject was discussed in the DUE (drug use in the elderly) Quarterly.

Dyspepsia (indigestion) affects 29 percent of the adult population and accounts for seven percent of visits to family physicians.

Most widely prescribed and used acid suppressing agents are:

-Proton pump inhibitors (PPI)- accounts for 90 percent of Alberta Blue Cross Group (ABCG) 66’s cost of acid suppression agents (examples-Losec, Prevacid, Pantaloc)

-H2 antagonists –accounts for 10 percent of the ABCG 66’s cost of acid suppression agents (examples-Zantac, Pepcid, Axid and their generic versions)

Why would one need these pills?

-For eradication of Helicobacter pylori organism from the stomach. A protocol requires that any patient with H. pylori infection, in the presence of an ulcer, should receive one week of “triple therapy” – two antibiotics and PPI. In the absence of an ulcer, the use of “triple therapy” is controversial.

-For gastroesophageal reflux disease (heart burn) – four to eight weeks of treatment with PPI or H2 antagonist is indicated with life-style changes.

-For functional dyspepsia, also known as non-ulcer dyspepsia or indigestion. In this condition, an individual has all the symptoms of an ulcer but no ulcer is found on investigations. A difficult condition to treat satisfactorily. A person may end up using the pills for prolonged period of time for symptomatic relief.

-For NSAID-related dyspepsia – individuals who are on non-steroid anti-inflammatory drugs (NSAID) are prone to peptic ulcer disease or indigestion. These individuals are on long-term use of stomach pills.

Losec should be taken half an hour before any meal, while Pantaloc and Prevacid should be taken before breakfast. These pills should be taken whole, not broken or chewed.
The Quarterly says that PPI have been recognized to be efficient and safe in what they do. And there is not much difference in the clinical use of the three PPIs except for the cost.

The cost comparison of PPIs in Alberta shows that Losec 20mg once daily costs $66.00 per month, Pantaloc 40mg once daily costs $61.26 per month and Prevacid 30mg once daily is the cheapest at $60.00 per month.

The largest group of patients on PPI are the ones with heartburn and gastroesophageal reflux disease. Many of these patients can be treated with life style changes and over the counter medications and/or cheaper H2 receptor antagonists like Zantac, Pepcid, or Axid. Those who do not respond to these measures can be stepped up to a PPI. These patients also require investigations to assess the degree of damage to the lining of the oesophagus by gastric and biliary juices.

The next large group on PPI is one with indigestion due to NSAID use. Patients who have peptic ulcer due NSAID therapy are best treated with PPI. NSAID patients are usually on another drug called misoprostal, which offers protection against development of ulcers.

Patients with non-ulcer dyspepsia should not be on long term PPI therapy without trial of other therapies, which are cheaper, and with minimal side effects. Prolonged acid suppression in the stomach without good reason may lead to atrophy of stomach glands and deficiency of vitamin B12. Plus the cost to the patient and other institutions that pay for the prescriptions.

So, if you are on any of the pills mentioned here on long term basis then ask your doctor: Do I really need it? Is there anything cheaper? Is there anything else you can do to relieve your symptoms?

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“Dr. B, its my indigestion. It is getting worse. Could it be an ulcer?” asks Susan as I enter the examination room.

Well Susan, what do you mean by indigestion?

“Dr. B, its my stomach!”

O.K. Susan, indigestion means different things to different people. Doctors describe indigestion as dyspepsia. Both terms are pretty vague. Medical text books describe this as a chronic (usually over 3 months), recurrent, often meal-related upper abdominal discomfort, pain or fullness.

Dyspepsia occurs in about 10 percent of the population. Most people carry on with off- the-counter medications. One-third of the people, who do seek help, will have no ulcer on investigations. This is called non-ulcer dyspepsia.

“Dr. B, what is an ulcer?” An ulcer is a break in the lining of an organ. The body responds to this with tissue reaction which may heal the ulcer or produce local tissue destruction with a crater formation.

There are 3 conditions to think about when a patient presents with indigestion: 1) ulcer of the stomach or duodenum (first part of small intestine), 2) cancer of the stomach and 3) non-ulcer dyspepsia.

Symptoms from gall bladder and pancreatic disease may mimic above conditions but they are more acute in nature with intervals where everything may be fine.

Clinically, I do not think Susan has cancer of the stomach as she is 38, has a good appetite and has not lost weight. Abdominal examination does not reveal any lumps.

Complicated ulcers can present with bleeding, weight loss, or vomiting and may mimic symptoms of cancer. Patients who are on non-steroidal anti-inflammatory drugs are prone to ulcers. In Susan’s case, there was no such history.

“Dr. B, what next? I have already tried off-the-counter medications. Is there a way to find the cause and treat it?”

Sure, Susan, let’s investigate with an ultrasound and gastroscopy. Ultrasound will check the gall bladder, liver and pancreas. Gastroscopy will examine the lining of the esophagus, stomach and duodenum.

Most of the ulcers in the stomach and duodenum are caused by Helicobacter pylori organisms (bugs). Biopsies taken during gastroscopy will identify whether these bugs are present. Gastroscopy will check for ulcer and cancer as well.

“Dr. B, you lost me! Gastroscopy? Helicobacter pylori………bugs? Scary stuff!

Susan, gastroscopy is not a difficult procedure. A flexible instrument with light and camera at the tip is swallowed under mild sedation. The magnified lining of the esophagus, stomach and duodenum are seen on a TV screen.

It allows us to do biopsies, remove polyps, dilate narrow areas, can often control bleeding and allows us to take photographs and video of the procedure.

Helicobacter pylori (H. pylori) is a bacteria found beneath the mucus layer of the stomach. In Canada, 10 to 20 percent of the population is infected with this organism. In developing countries, most people are infected before the age of 10 years.

It is estimated that 1 in 5 individuals with H. pylori will develop gastric or duodenal ulcer. A very small percentage may develop cancer of the stomach.

Susan’s ultrasound is normal. Gastroscopy reveals a duodenal ulcer with presence of H. pylori infection. Susan is treated for seven days with “triple therapy” – two antibiotics and an acid reducing agent.

Response rate to this therapy is over 90 percent for healing the ulcer and eradicating the bugs. The risk of recurrent infection is 1 to 3 percent over 5 years, usually from the immediate environment.

Susan feels great and is happy that we are able to identify the cause and treat it. A classic example of modern technology at work!

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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“Doc, it’s my heartburn. I am getting sick and tired of this,” said Dave as I settled down on my chair. “Doc, can we get this under control?”

Sure Dave, we can. First, we should try and understand what is heartburn. What is the mechanism behind this symptom? Does it need any investigations? Then we can talk about treatment.

“Ok Doc, shoot!”

Esophagus is a long hollow muscular tube. It is about 40 cm long in an adult and crosses the chest behind the heart and in between the lungs. It connects two separate anatomical areas: mouth above the neck and the stomach below the diaphragm (in the abdomen).

Esophagus allows food, drinks and saliva to go down in to the stomach but prevents stomach contents to flow back. This control is achieved by the upper and lower esophageal sphincters.

Heartburn is a burning sensation felt behind the middle of the chest. It is worse in certain positions (bending, lying down). Certain foods, obesity and anxiety can aggravate the symptoms. The sensation of burning is created by the reflux of stomach contents – usually acidic – into the esophagus.

Why does the lower esophageal sphincter (LES) fail to prevent reflux? The mechanism is complex. But simply put, the LES tone may be decreased or there may be inappropriate relaxation of the sphincter. The normal anatomy of the LES may be disturbed by obesity or hiatus hernia.

Hiatus hernia is a condition where by the junction of the esophagus and stomach (site of LES) slides up into the chest through the opening in the diaphragm from its normal position in the abdomen.

Reflux or heartburn can occur with or without hiatus hernia. Hiatus hernia and heartburn each occurs in about 30 percent of the population. Therefore some overlap can be expected.

About 35 percent of the population have experienced heartburn in their lifetime and about 10 percent suffer from this at least once a week. Most people treat themselves with off the counter medications and do not even complain to their doctors.

Should we investigate all patients who complain of heartburn? Clinically uncomplicated heartburn does not require investigation to start with. This is first treated with advice on change in lifestyle (lose weight, reduce or stop smoking) and off the counter antacids. Elevation of the head end of the bed will help keep the acid in the stomach when lying down.

Dave follows this advice for six weeks and is no better. “Dave, let us try acid reducing medication. If this does not help in the next couple weeks then add a prokinetic agent. This will empty your stomach better and strengthen LES.”

Dave is no better. Now he has difficulty swallowing. He is anemic. He has pain in the middle of the chest. These are features of complicated gastro-esophageal reflux disease. He is booked for gastroscopy and biopsies to check for ulcer or cancer.

Gastroscope is a lighted flexible instrument to examine the lining of the esophagus, stomach and duodenum. This test is done under mild sedation. Dave has a moderate size hiatus hernia with inflammation and ulceration. Biopsy reveals no cancer.

Dave is given a new prescription with higher dosage for acid reducing and prokinetic pills. Iron pills are prescribed to correct anemia. Dave responds to this treatment very well. He is now on maintenance therapy.

Dave could have had gastroscopy earlier if he did not respond to medications prescribed or relapsed after initial positive response. But his symptoms advanced rapidly and cancer was strongly suspected.

“Thank you, doc,” said delighted Dave. “I am glad there is no cancer.”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!