Treatment of Peptic Ulcer Disease and Nonulcer Dyspepsia

Journal of Family Practice, July, 2001 by Linda N. Meurer

Antisecretory treatments were more effective than placebo in the treatment of NUD, with a number needed to treat of 6 for [H.sub.2]-RAs and 11 for PPIs (ie, for every 11 patients who received a PPI instead of placebo, one benefited).[24] Thus, PPIs were actually less effective than [H.sub.2]-RAs in this meta-analysis of placebo-controlled trials. Long-term use of antisecretory therapy may be associated with hypergastrinemia, increased gastrointestinal bacterial counts, and altered absorption of nutrients, though the clinical significance of this is unclear.[27] For patients who do not respond to acid-suppressive therapy it might be necessary to entertain alternative diagnoses, and if no explanation for the symptoms can be identified, consider counseling or pain management strategies to help the patient cope with the discomfort. Studies of the use of antidepressants, though small and of questionable quality, consistently show improvement in symptoms of patients with functional gastrointestinal disorders, including NUD and irritable bowel syndrome.[28] Treatment recommendations for NUD are shown in Table 4.

TABLE 4
TREATMENT OPTIONS FOR NONULCER DYSPEPSIA (NUD)

Strength of      Treatment            Comment
Recommendation

B                [H.sub.2] blockers   Studies of poor quality,
                                        small, short duration and
                                        without validated outcome
                                        measures

B                PPIs                 Studies of poor quality,
                                        small, short duration and
                                        without validated
                                        outcome measures

B                Prokinetics          Cisapride associated with
                                        adverse cardiac events and
                                        is no longer available.
                                        Evidence not based upon
                                        studies of metoclopramide.
                                        May be most effective in
                                        patients with dysmotility
                                        symptoms.[38]

B                Antidepressants      Small studies of questionable
                                        quality consistently showed
                                        decrease in symptoms in
                                        functional gastrointestinal
                                        disorders (NUD and IBS)

D                Antacids             No direct evidence of benefit

PPIs denotes proton-pump inhibitors; IBS, irritable bowel syndrome.

To date there is no convincing evidence that empiric eradication of H pylori in patients with NUD improves symptoms. One recent meta-analysis of randomized controlled trials revealed no improvement with H pylori eradication for the symptoms of NUD,[29] while 2 others[25,30] showed a modest but statistically significant benefit, with 1 patient cured for every 19 treated (number needed to treat = 19).