The use of consensus to develop guidelines for the management of Helicobacter pylori infection in primary care. European Society for Primary Care Gastroenterology.
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BACKGROUND: Guidelines are an increasingly important feature of clinical practice and have proliferated over the past decade. When the evidence base for effective practice is limited, guidelines have to derive from the opinions and experience of those with knowledge of the subject. The manner in which a group synthesizes its individual opinions, the consensus process, is central to the validity and applicability of the resulting recommendations. This paper considers the theoretical issues in consensus development and describes the consensus process used in developing the European Society for Primary Care Gastroenterology guidelines for the management of Helicobacter pylori in primary care. METHODS: A consensus development conference of 48 GPs from nine European countries used case scenarios to define clinical management strategies in dyspepsia and H.pylori infection. Structured data collection from this meeting allowed a quantitative measure of the extent of consensus to be produced. RESULTS: Specific recommendations were produced for 15 decision points relevant to the management of H.pylori infection in primary care. DISCUSSION: Consensus development is often utilized in the production of guidelines for clinical practice. Guideline appraisal instruments fail to examine in depth the methods used for this important part of the development process. We describe an approach to consensus development which contains a simple measure of the strength of consensus underlying each recommendation. (+info)
Guidelines on the management of H.pylori in primary care: development of an implementation strategy.
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BACKGROUND: Clinical guideline programmes as being developed in many European countries contribute to quality of care in general practice. The applicability of multicountry guidelines will depend on country-specific circumstances. Implementation programmes are required for optimal compliance with guidelines. OBJECTIVE: In order to achieve optimal follow-up of the European Society for Primary Care Gastroenterology (ESPCG) Helicobacter pylori guidelines in general practice, we analysed factors that might obstruct compliance at national level, and integrated this in implementation programmes. METHOD: Discussion groups in eight participating countries reviewed epidemiological characteristics and diagnostic and therapeutic resources that would hinder applicability. The groups also indicated potential constraints to optimal compliance and developed a national implementation programme. RESULTS: Helicobacter pylori infection rates and peptic ulcer incidence vary widely across Europe, as do the availability, access and reimbursement of diagnostic test facilities for H.pylori Minor adaptation of the ESPCG guidelines is required in some countries. Implementation programmes have been developed and partially carried out in all countries. CONCLUSION: A pan-European approach to H.pylori guideline development should result in a framework of best practice into which nationally specific details can be incorporated, thus guaranteeing optimal follow-up of the guidelines and true improvement of dyspepsia management in primary care. (+info)
Helicobacter pylori and peptic ulcer disease--a causal link.
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The link between Helicobacter. pylori and peptic ulcer disease in 1997 is an irrefutable one. The association between infection and ulcerogenesis has been shown to be biologically plausible with induction of epithelial inflammation and cell damage and its effect on gastrin/acid homeostasis. The association of H. pylori infection and peptic ulcer disease is a close and consistent one. There is ample evidence indicating that H. pylori eradication results in virtual abolition of ulcer relapse. Several studies have demonstrated that eradication of H. pylori results in ulcer healing and there is evidence showing a temporal relationship between infection and development of peptic ulcer disease. (+info)
Prevalence of CagA and VacA antibodies in children with Helicobacter pylori-associated peptic ulcer compared to prevalence in pediatric patients with active or nonactive chronic gastritis.
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VacA and CagA serological responses were detected in pediatric patients: 44 and 56%, respectively, in peptic ulcer (PU) patients, 33.3 and 44.4% in active chronic gastritis (ACG) patients, and 23.2 and 39.2% in non-ACG patients. Higher seroprevalence to CagA+VacA and to CagA+VacA+35-kDa antigen was found among PU patients. However, a low level of sensitivity and specificity was found for indirect detection of PU patients. (+info)
Proton pump inhibitor therapy: preliminary results of a therapeutic interchange program.
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OBJECTIVE: To analyze the experience of one Department of Veterans Affairs hospital in treating with lansoprazole all patients with acid-peptic disease requiring proton pump inhibitor therapy, including newly diagnosed patients and those who were previously stabilized on omeprazole. STUDY DESIGN: Retrospective analysis. PATIENTS AND METHODS: We evaluated the charts of 78 patients seen between March 17, 1997, and November 1998 by the Gastroenterology Section at the Togus Veterans Administration Hospital who were diagnosed with acid-peptic disease. RESULTS: Overall, side effects necessitated discontinuation of therapy in 10 (13%) of the lansoprazole-treated patients and none of the omeprazole-treated patients. Nine patients on lansoprazole suffered from persistent diarrhea and were placed on omeprazole, and one had lower back pain and was switched to cimetidine therapy. Additionally, 12 patients (15%) had their lansoprazole therapy discontinued because of lack of efficacy. Of the 78 lansoprazole-treated patients, 22 (28%) failed to respond to treatment. CONCLUSIONS: Although this study represents preliminary findings and the statistics are observational in nature, important lessons can be learned. At this particular institution, the potential 12% savings from a mandated therapeutic interchange program were quickly offset by the overall lansoprazole-associated failure rate of 28%. The reproducibility of these preliminary results from an omeprazole-to-lansoprazole therapeutic interchange program in other institutions is unknown but warrants further consideration and additional studies, including those evaluating cost efficacy. (+info)
New therapeutic options in the treatment of GERD and other acid-peptic disorders. Based on a presentation by Duane D. Webb, MD, FACG.
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Gastroesophageal reflux disease (GERD), or the regurgitation of gastric content into the esophagus, is an acid-peptic disorder that has a significant impact on both health and the quality of life. Because gastric acid plays a major role in the pathophysiology of this disease, acid neutralization/suppression has emerged as the cornerstone of GERD therapy. Currently, there are 3 classes of drugs used to increase gastric pH: antacids, histamine2 receptor antagonists (H2RAs), and proton pump inhibitors (PPIs). Antacids act by neutralizing the pH of the stomach. However, because of their limited efficacy and short duration of action, they have not been shown to be effective in either the prevention or healing of GERD-induced esophageal injury. Moreover, numerous doses per day are often required to control GERD symptoms. A second class of agents, H2RAs, act by inhibiting a histamine-dependent biochemical pathway that stimulates acid secretion by the gastric parietal cell. However, because there are several other stimulatory pathways that also contribute to acid secretion, a lack of consistent efficacy of H2RAs exists among individuals. Moreover, because there are several pathways leading to acid secretion, patients who receive H2RAs often experience tachyphylactic reactions to these drugs. The PPIs are the latest and most effective medications for the treatment of GERD. Unlike H2RAs, PPIs block acid secretion at its source--the proton pump of the gastric parietal cell. Studies have consistently shown that PPIs are more effective than H2RAs in resolving GERD symptoms, healing erosive esophagitis, and preventing esophageal injuries. PPIs are also effective in the treatment of acid-peptic disorders other than GERD, such as duodenal and gastric ulcers. Four PPIs are currently available in the United States: omeprazole, lansoprazole, rabeprazole, and pantoprazole. (+info)
Pharmaceutical interference with the [14C] carbon urea breath test for the detection of Helicobacter pylori infection.
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Helicobacter pylori bacteria reside in the mucosal lining of the stomach where, due to a variety of factors, the infection predisposes patients to peptic ulcer disease. Detection of H. pylori is important in the treatment and follow-up of patients with peptic ulcer disease and the urea breath test is the method of choice. This article will briefly review the methods for diagnosing H. pylori, emphasizing the [(14)C]urea breath test. The agents which can interfere with the results of the breath test will be reviewed and the role of the consulting pharmacist will be discussed. (+info)
Third line treatment for Helicobacter pylori: a prospective, culture-guided study in peptic ulcer patients.
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BACKGROUND: A third line treatment is needed in roughly 5% of patients infected with Helicobacter pylori. Few data have been reported on efficacy of treatment regimens in these patients. METHODS: A prospective trial was designed to study the effectiveness of third line treatment of H. pylori infection in ulcer patients. Two-week quadruple, culture-guided, combinations were used in 31 consecutive patients. Susceptibility to metronidazole and clarithromycin were studied by E-test, and thereafter a predetermined treatment regimen was used. Compliance was evaluated by pill count, and eradication defined by negative urea breath test at 6 weeks. RESULTS: Two main quadruple regimens were used in 29 patients. In spite of good compliance, the combination of omeprazole, tetracycline, bismuth and clarithromycin (OTBC) showed an eradication rate (per protocol analysis) of 36% (five out of 14; CI: 12.8-64.9), and if amoxycillin was used (OTBA) the rate was 67% (eight out of 12; CI: 34.9-90.1). The difference was not significant. No clinical factor was found to be associated with failure to eradicate. CONCLUSIONS: Third line treatment often fails to eradicate H. pylori infection. New strategies need to be developed and tested for this common clinical situation. (+info)