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Management of dyspepsia: the role of the nurse

Charles Broomhead
MB ChB MRCGP DA DRCOG
GP and GP
Trainer
Sutton Coldfield
Honorary Clinical Lecturer
Birmingham Medical School
E:charles.broomhead@lineone.net

The concept of prescribing by nurses is at last becoming well established and being accepted in both primary and secondary care. Implementing this has been a slow process, with negotiation and consultation dating back to at least 1989.(1) Increasingly we are witnessing the establishment of "patient group directions", "supplementary prescribers" and "independent nurse practitioners". With the imminent introduction of the new GP contract the speed of this process will inevitably accelerate, arguably freeing up GPs to utilise more of their unique skills. There can be no doubt that there are many conditions that can be managed as well, or perhaps even better, by nurses rather than their doctor colleagues. Recognising this, the government is introducing legislation that will allow independent nurse prescribers to manage a range of specified medical conditions. A full list of these can be found on the Department of Health nurse prescriber's website (see Resources section). There can be few who do not think that this list will expand considerably in years to come, but already there are more than 30 conditions, including "heartburn", for which nurse prescribing is deemed appropriate.

Prevalence
Heartburn, GORD (gastro-oesophageal reflux disease) and other acid-related disorders are common problems. In one UK survey 40% of adults reported having one or more dyspeptic symptoms in the previous year,(2) while the prevalence rises to 59% or more in those over the age of 65 years.(3,4) An estimated 10% of the population consult their GPs about dyspepsia each year and of these about 10% are then referred to secondary care. In other words, the overwhelming majority of patients are managed without the benefit of specialist advice. These are the sorts of conditions that are often considered appropriate for nurse management and while this may be true there are a number of potential pitfalls that must be borne in mind.
 
Diagnosis
Dyspepsia is a symptom or a collection of symptoms and not a diagnosis in its own right, although most of us have suffered from and recognise the condition that the patient is describing. Some of its more common features include abdominal discomfort, bloating, flatulence, nausea and vomiting, and heartburn. Not only may conditions such as ischaemic heart disease masquerade as dyspepsia (and vice versa), but there is also the possibility of some other underlying sinister pathology such as a gastric or oesophageal malignancy. One of the most difficult things to do is to decide whether the patient in front of you needs further investigation or whether it is appropriate to treat them on symptomatic grounds alone. This is a dilemma for which there is no simple solution and it would be relatively easy to refer huge numbers of patients for endoscopy, a procedure that is not without its own inherent dangers. The age and sex of the patient and the duration of symptoms are certainly important considerations, as is the reassurance of negative physical examination. Symptoms that will raise the level of concern include a complaint of weight loss or dysphagia, and patients who disclose such a ­history must be investigated urgently.

General management issues
There are some common principles of management that apply to all patients regardless of whether they are also prescribed or advised to buy medication. These include advice about losing weight, stopping smoking, reducing alcohol consumption and the size, timing and frequency of meals.
It is night-time symptoms that often prove to be the most difficult to control but simple measures such as advice to raise the head of the bed may prove effective. Using extra pillows generally doesn't work as the patient usually slips off them while asleep and awakes to find themselves lying flat once more.

Problems in the elderly
The management of dyspepsia in elderly patients poses particular diagnostic and therapeutic problems. These patients often complain of less severe or less frequent symptoms than younger people, even though they tend to have more severe disease, perhaps as a result of exposure of their oesophagus to gastric acid, pepsin and bile over many years. As there is a significantly higher chance that an elderly patient has an underlying organic cause such as a malignancy, it is this group that warrants early and thorough investigation. Maintaining a high index of clinical suspicion is crucial when treating an older dyspeptic, particularly when they present for the first time.
Age-related factors such as reduced salivary secretion, delayed oesophageal clearance and gastric emptying, and a reduction in lower oesophageal sphincter tone can all exacerbate the problem. It's an inescapable fact that the elderly tend to be those who require multiple medications for other concomitant conditions and drugs such as calcium channel blockers, b-blockers, nitrates and benzodiazepines have all been shown to cause relaxation of the gastro-oesophageal sphincter. Similarly the use of bisphosphonates, aspirin or NSAIDs (nonsteroidal anti-inflammatory drugs) may aggravate the situation.
There are a number of possible therapeutic approaches when treating patients for dyspepsia and several of these options are available over-the-counter (OTC) without prescription. Drugs that are used to treat dyspepsia can work in one of four, although not necessarily exclusively, different ways. They may neutralise the refluxing gastric acid, protect the oesophageal mucosa, encourage oesophageal peristalsis, or reduce the secretion of gastric acid.

Antacids
Antacids are cheap and are freely available OTC but must be used cautiously in elderly patients. Used intermittently they can be useful in the symptomatic relief of mild reflux, but their acid-neutralising abilities are relatively weak and as a result it is often necessary to take them in large amounts in order to produce much improvement. Many contain significant quantities of sodium, which as a consequence may lead to water retention and the exacerbation of concomitant conditions such as hypertension or heart failure. Side-effects are not infrequent - constipation is associated with aluminium-based products while those containing magnesium salts tend to cause diarrhoea. Additionally they may interfere directly with the absorption of other medication, in particular antibiotics, or indirectly by damaging the enteric coating of drugs designed to avoid gastric dissolution. Generally the use of antacids containing bismuth or calcium is not now considered desirable due to their potential to cause toxic side-effects.
Adding an alginate to the antacid, for example in Gaviscon (Britannia), may confer some additional benefits. The rationale for its use is that a protective raft is formed on the surface of the stomach contents and if reflux takes place, this then coats the oesophageal mucosa and protects it from the effects of gastric acid.
Dimethicone is sometimes added to antacids as an antifoaming agent. It is claimed by some that this reduces flatulence but the objective evidence for this is scant.

Prokinetic drugs
These drugs are often useful either on their own or in conjunction with an antacid, H(2)-blocker or proton pump inhibitor (PPI), and can be particularly effective when symptoms such as nausea, vomiting or bloating are present. Metoclopramide is widely used in this context but it may not represent the best choice in elderly patients, up to one third of whom will experience side-effects. These can include tremors, muscle spasm, agitation, insomnia, drowsiness, confusion and tardive dyskinesia. Domperidone is probably a better choice for an elderly patient due to its absence of CNS side-effects.

H(2)-receptor antagonists and PPIs
In the main H(2)-blockers are safe and effective although adverse changes in mental states have been described in elderly patients with both cimetidine and ranitidine.(5) It is a problem that is particularly marked in those with renal or hepatic dysfunction. Although these were "state-of-the-art" drugs in the 1970s when they were first introduced, they remain relatively expensive drugs and PPIs have now largely superseded them. Indeed many now consider them to be the ­treatment of choice for GORD.
PPIs have an excellent safety profile and there is generally no need to reduce the dose in elderly patients, even where they are known to have mild hepatic or renal impairment. Care does need to be taken if prescribing any PPI where liver disease is severe. All of them are metabolised by the hepatic cytochrome P450 isoenzyme system and hence have some inherent potential for drug interactions. At present there are five PPIs available in the UK. In general the newer drugs such as pantoprazole, rabeprazole and esomeprazole may be considered as most suitable for the elderly due to their lower potential for interaction with other prescribed medications. Only one of this class of drug, esomeprazole, has a licence for "PRN" (as required) use although it is a fact that is commonly ignored, and lansoprazole is the only one that is available as a suspension.

Summary
As is so often the case the key to good management lies in understanding and adhering to established protocols. Taking a careful and focused history will usually allow many patients to be successfully managed in primary care and will identify those most at risk of having more serious disease. Understanding the way in which the different classes of drugs work allows them to be prescribed in a logical and effective manner.
Perhaps one of the greatest challenges that remains for us is to persuade patients to modify their lifestyle and thereby avoid what almost amounts to an addiction to highly expensive medication.

References

  1. Department of Health. Report of the advisory group on nurse prescribing. London: Department of Health; 1989.
  2. Logan R, Delaney B. Implications of dyspepsia for the NHS. BMJ 2001;323:675-7.
  3. Quatu-Lascar R, Triadafilopoulos G. Oesophageal mucosal diseases in the elderly. Drugs Aging 1998;12:261-76.
  4. Nebel OT, Fornes MF, Castell DO. Symptomatic gastro-oesophageal reflux: incidence and precipitating factors. Am J Dig Dis 1976;21:953-6.
  5. Lippy RJ, Fennerty B, Fagan TC. Clinical review of ­histamine-receptor ­antagonists. Arch Intern Med 1990;150:745-55.

Resource
Department of Health Nurse Prescribing page
W:www.doh. gov.uk/nurseprescribing/pomlist.htm