28 | Nursing in Practice | Summer 2023
is available locally . Many areas now use a stool antigen test – ensure the patient understands what sample they are meant to give , as it is common for the test to come back as ‘ no result – urine sample received instead of stool ’. A blood test for the antibody to H . pylori has largely fallen out of usage , mainly because it has sensitivity and specificity that are sometimes as low as 50 % 10 , so you might get just as accurate an answer from tossing a coin . The patient should avoid antibiotics for four weeks and acid suppression for two weeks before doing the test .
If the test is positive then the patient needs a one-week course of eradication , using one of the regimens listed in the BNF and in box 2 on page 29 . 11
Ongoing symptoms Many patients will find symptoms settle after treatment and some lifestyle changes , but that isn ’ t always the case . A tricky group of patients are those who have had a reason to use a long-term NSAID or aspirin , which they can ’ t stop ; options in such cases include reducing the dose of the drug , considering the use of a cox-2 inhibitor such as etoricoxib , or using long-term acid suppression with a PPI . Ongoing symptoms should also prompt a review of the history , looking for signs of an alternative diagnosis or new red flags . It may be worth redoing the H . pylori test , particularly if adherence to the eradication therapy was poor , the original test was done within two weeks of taking a PPI or four weeks of taking antibiotics , the symptoms are severe , there is a family history of gastric malignancy or the patient is very anxious and keen to have retesting . 5
Refractory symptoms , despite optimal management in primary care and second-line treatment of H . pylori , should prompt referral either to a gastroenterologist , or for direct-access endoscopy . Patients must stop any acid suppression therapy for at least two weeks before an OGD , though they could use an alginate such as Gaviscon to manage symptoms if needed . An OGD may find an ulcer , oesophagitis or gastritis , a malignancy or Barrett ’ s oesophagus ( a pre-malignant stage that is a risk factor for oesophageal cancer ). It may also reveal a hiatus hernia that is aggravating symptoms and may need corrective surgery .
Functional dyspepsia If your patient has gone all the way down this path and ended up with a normal OGD , then they have functional dyspepsia , otherwise known as non-ulcer dyspepsia ; the prevalence of this is around 8 % to 12 %. 12 Symptoms will improve spontaneously in about one-third and persist in the remainder . A proportion of the latter group will end up on long-term acid suppression with a PPI , with other options including tricyclic antidepressants to alter pain perception and help with relaxation of the stomach ( gastric accommodation ). There is inconsistent evidence for probiotics but they are unlikely to do any harm and patients might wish to try them over the counter . 12
Long-term PPI use Unfortunately , long-term use of a PPI is not without its complications . The chronic increase in gastric pH it causes can lead to deficiencies of vitamin C , vitamin B12 , iron , calcium and magnesium , as all of these need gastric acid to be absorbed in the stomach . 13 There is also a 45 % increase in the risk of gastric cancer , although the absolute risk remains low : if 2,121 people take a PPI for five years , or 1,191 for 10 years , there will be one extra case of stomach cancer . 14 We are all busy in primary care and it is very easy when signing prescriptions to see that someone has been on a PPI for years and just click to authorise another year . But if a team member has the time , it is a useful quality-improvement project to look at the group of long-term PPI users and see if any can come off the drug . It might be a job for a practice pharmacist , or a GP trainee looking for an audit for their portfolio .
Overprescribing In the process of doing this , they could become acquainted with the useful website deprescribing . org . 15 Overprescribing and polypharmacy is a huge issue in the NHS , with 8.4 million people in England regularly prescribed five or more medicines and adverse effects causing 20 % of hospital admissions in the over-65s . 16 Deprescribing . org has a whole section on PPIs , including a patient-facing infographic pointing out possible side-effects ( nausea , headaches , diarrhoea ) and that around half of people who are admitted while taking a PPI have no documented long-term reason for the drug . The website links to an evidence-based protocol for the deprescribing of PPIs 17 . This does not apply to those with Barrett ’ s oesophagus , severe oesophagitis or a history of bleeding ulcers , who are all likely to all need a long-term PPI . The principles of PPI deprescribing are listed in box 3 .
Summary Dyspepsia and GORD are common conditions that can largely be managed in primary care after careful history and examination , referring only those who need a secondary care opinion either due to cancer risk or refractory symptoms . The effectiveness of PPIs can lead to unintended overprescribing so we should also be aware of patients who are using this drug long-term , and whether they would benefit from trying to cut down .
Box 3 Principles of PPI deprescribing
Dr Toni Hazell is a GP in north London
• Start by gradually decreasing to the lowest possible dose and then changing from regular to as-needed use .
• Review at four weeks and 12 weeks , more often if needed .
• Remind the patient about lifestyle changes that can reduce the need for PPI use .
• Warn the patient about the possibility of rebound hyperacidity : – After a period of PPI use , the stomach increases release of the hormone gastrin , which stimulates gastric acid . – When the PPI is stopped , gastrin will remain high for a time , causing an increase of symptoms . – This should return to normal within a fortnight and can be managed with alginates ( e . g . Gaviscon ) or H2 receptor antagonists . – A patient who has been warned about rebound hyperacidity is probably less likely to restart
18 , 19 their PPI when it occurs , so give them access to good patient information on this topic .
ALAMY