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H. pylori - the bandwagon starts to roll

In Bandolier 2 we carried a major feature on Helicobacter pylori , a microbacterial infection which is closely related both to duodenal ulcer and to gastric cancer. Each month new articles are published and the management of recurrent upper abdominal pain becomes more complex.

Upper abdominal pain is big business. For each million of the population, about £3 million per annum is spent on upper abdominal pain medication, mostly medication to control acid production, with omeprazole being one of the fastest increasing drugs in the UK at present. In one region where there was concern about ranitidine costs it came as a surprise to note that expenditure on ranitidine had hardly changed during 1993/94, whereas expenditure on omeprazole had increased by 80 percent. In addition to the £3 million per million population spent on medication, a considerable amount of money, perhaps between £0.5 million to £1 million, is spent on investigation with endoscopy referral rates increasing steadily. Two new twists to the H. pylori saga have developed in the last few months.

Diagnosing H. pylori infection

Manufacturers have been busy developing machines to diagnose H. pylori infection. One edition of Medical Laboratory World carried two features on instruments for measuring salivary antibodies against H. pylori and some clinical teams may well start this test. But it is not clear how knowledge of the presence or absence of salivary antibodies aids either diagnosis or treatment. There appears to be no need to include this in specifications for 1995/96.

The March edition of Medical Laboratory World carried a feature on a much larger piece of machinery (as big as a room) which can measure the concentration of urea in the breath. This not only indicates the presence or absence of H. pylori infection but also gives some indication of the activity of infection. It does not, however, appear to make a useful contribution to the management of upper abdominal pain, and urea breath testing should also be excluded from any specification for GI medicine or surgery being written for 1995/6.

Recurring prescribing

A very important article from the Department of Gastroenterology at Northwick Park Hospital [1] showed just how high the prevalence of acid suppressing treatment is in the population. In a survey of 60,148 patients in seven practices they found that 0.82 percent of the population (492 patients) was taking long-term treatment; three quarters had been taking continuous treatment for more than five years at the time of the survey.

However, "a substantial number of patients are taking these drugs long-term without a diagnosis having been reached"; 19 percent were being treated for abdominal pain with no diagnosis or with only the diagnosis of gastritis based on endoscopic examination. In addition, 37 out of the 492 patients were also taking either prescribed non-steroidal anti-inflammatory drugs or regular aspirin or ibuprofen.

Guidelines have been implemented after analysis of these results and the impact of these guidelines on prescribing practice will be monitored. This important study supported by the North West Thames Regional Audit Fund, emphasises the need to get research into practice and reach agreement about the implications of research findings for informed patient choice, effective prescribing, and the purchasing of gastroenterology services which give good value for money.

Substantial increases in prescribing of acid-suppressing drugs, especially omeprazole, have been noted in the last several years, and data for the Oxford Region in 1992 and 1993 are shown in the Figure. If omeprazole is increasing, why aren't the others falling? Despite FHSA pressure to switch from ranitidine to cimetidine there is no evidence that this had any effect by the last quarter of 1994.

1: SD Ryder , S O'Reilly, RJ Miller, J Ross, MR Jayyna, AJ Levi. Long term acid suppressing treatment in general practice. British Medical Journal 1994 308: 827-30.

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