2 dys print qrg update

National Institute for
Clinical Excellence
Issue date: August 2004
Quick reference guide
Dyspepsia – management of
dyspepsia in adults in
primary care
In June 2005 the recommendations on referral for endoscopy in the NICE guideline ondyspepsia were amended in line with the recommendation in the NICE ClinicalGuideline on referral for suspected cancer (NICE Clinical Guideline no. 27: Referralguidelines for suspected cancer. June 2005. See www.nice.org.uk/CG027). This quickreference guide has been amended to take account of the changes in the NICEguideline (see pages 2, 3, 5, 6 and 13).
For ease of reference, the original text in this document has been struck through andthe revised text has been set in italics below it.
Clinical Guideline 17
Developed by the Newcastle Guideline Development and
Research Unit
This guidance is written in the following context:
This guidance represents the view of the Institute, which was arrived at after careful consideration
of the evidence available. Health professionals are expected to take it fully into account when
exercising their clinical judgement. The guidance does not, however, override the individual
responsibility of health professionals to make decisions appropriate to the circumstances of the
individual patient, in consultation with the patient and/or guardian or carer.
National Institute for
Clinical Excellence
MidCity Place71 High HolbornLondon WC1V 6NA ISBN: 1-84257-783-2Published by the National Institute for Clinical ExcellenceAugust 2004Printed by Abba Litho (Sales) Ltd, London National Institute for Clinical Excellence, August 2004. All rights reserved. This material may be freely reproducedfor educational and not-for-profit purposes within the NHS. No reproduction by or for commercial organisations isallowed without the express written permission of the National Institute for Clinical Excellence.
Contents
Gastro-oesophageal reflux disease, peptic ulcer and non-ulcer dyspepsia Heliocobacter pylori: testing and eradication Key priorities for implementation
use is necessary before testing for H. pyloriwith a breath test or a stool antigen test.
● Review medications for possible causes of dyspepsia (for example, calcium antagonists, Interventions for gastro-oesophageal reflux nitrates, theophyllines, bisphosphonates, ● Offer patients who have GORD a full-dose PPI inflammatory drugs [NSAIDs]). In patients requiring referral, suspend NSAID use.
● Urgent specialist referral for endoscopic treatment, offer a PPI at the lowest dose investigation* is indicated for patients of any possible to control symptoms, with a limited any of the following: chronic gastrointestinal bleeding, progressive unintentional weight ● Offer H. pylori eradication therapy to H. pylori-positive patients who have peptic ulcer persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal.
● For patients using NSAIDs with diagnosed ● Routine endoscopic investigation of patients peptic ulcer, stop the use of NSAIDs where of any age, presenting with dyspepsia and possible. Offer full-dose PPI or H2RA therapy without alarm signs, is not necessary.
for 2 months to these patients and if H. pylori is present, subsequently offer eradication Helicobacter pylori (H. pylori) testing and acid suppression therapy, and when patients ● Management of endoscopically determined have one or more of the following: previous non-ulcer dyspepsia involves initial treatment gastric ulcer or surgery, continuing need for for H. pylori if present, followed by NSAID treatment or raised risk of gastric ● Routine endoscopic investigation of patients ● Re-testing after eradication should not be of any age, presenting with dyspepsia and offered routinely, although the information without alarm signs, is not necessary. However, in patients aged 55 years and older with unexplained** and persistent** recent- onset dyspepsia alone, an urgent referral for Interventions for uninvestigated dyspepsia ● Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. ● A return to self-treatment with antacid pylori. There is currently insufficient evidence and/or alginate therapy (either prescribed or to guide which should be offered first. A 2- NICE guideline: quick reference guide – dyspepsia Key priorities for implementation (continued)
** In the referral guidelines for suspected cancer (NICE Clinical Guideline no. 27), ‘unexplained’ is ● H. pylori can be initially detected using either defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary antigen test, or laboratory-based serology care professional after initial assessment of the history, examination and primary care investigations (if any)’. In the context of thisrecommendation, the primary care professional ● Office-based serological tests for H. pylori should confirm that the dyspepsia is new rather than a recurrent episode and exclude common precipitants of dyspepsia such as ingestion ofNSAIDs. ‘Persistent’ as used in the ● For patients who test positive, provide a recommendations in the referral guidelines refers to the continuation of specified symptoms and/or consisting of a full-dose PPI with either signs beyond a period that would normally be associated with self-limiting problems. The 250 mg or amoxicillin 1 g and clarithromycin precise period will vary depending on the severityof symptoms and associated features, as assessed by the healthcare professional. In many cases, the * The Guideline Development Group considered upper limit the professional will permit symptoms that ‘urgent’ meant being seen within 2 weeks.
and/or signs to persist before initiating referralwill be 4–6 weeks. NICE guideline: quick reference guide – dyspepsia 1 Community care and pharmacy
Flowchart to guide pharmacist management of dyspepsia Dyspepsia
Advise to see
Advise to see
No further advice
GP routinely
GP urgently
1 Alarm signs include dyspepsia with gastrointestinal bleeding, difficulty swallowing, unintentional weight loss, abdominal swelling and persistent vomiting.
2 Ask about current and recent clinical and self care for dyspepsia. Ask about medications that may be the cause of dyspepsia, for example, calcium antagonists, nitrates,theophyllines, bisphosphonates, corticosteroids and NSAIDs.
3 Offer lifestyle advice, including advice about healthy eating, weight reduction and 4 Offer advice about the range of pharmacy-only and over-the-counter medications, reflecting symptoms and previous successful and unsuccessful use. Be aware of the fullrange of recommendations for the primary care management of adult dyspepsia to workconsistently with other healthcare professionals.
NICE guideline: quick reference guide – dyspepsia 2 Presentation at GP and endoscopy
Flowchart of referral criteria and subsequent management New episode of
dyspepsia
Return to
self care
Refer to specialist
1 Immediate referral is indicated for significant acute gastrointestinal bleeding. Consider the possibility of cardiac or biliary disease as part of the differential diagnosis.
Urgent specialist referral* for endoscopic investigation is indicated for patients of any agewith dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding,progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting,iron deficiency anaemia, epigastric mass or suspicious barium meal.
Routine endoscopic investigation of patients of any age, presenting with dyspepsia andwithout alarm signs, is not necessary. However, for patients over 55, consider endoscopy whensymptoms persist despite Helicobacter pylori (H. pylori) testing and acid suppression therapy,and when patients have one or more of the following: previous gastric ulcer or surgery, NICE guideline: quick reference guide – dyspepsia 2 Presentation at GP and endoscopy (continued)
continuing need for NSAID treatment or raised risk of gastric cancer or anxiety about cancer.
Routine endoscopic investigation of patients of any age, presenting with dyspepsia andwithout alarm signs, is not necessary. However, in patients aged 55 years and older withunexplained** and persistent** recent-onset dyspepsia alone, an urgent referral forendoscopy should be made.
Consider managing previously investigated patients without new alarm signs according toprevious endoscopic findings.
2 Review medications for possible causes of dyspepsia, for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and NSAIDs. Patients undergoingendoscopy should be free from medication with either a proton pump inhibitor (PPI) or an H2receptor (H2RA) for a minimum of 2 weeks. * The Guideline Development Group considered that ‘urgent’ meant being seen within ** In the referral guidelines for suspected cancer (NICE Clinical Guideline no. 27), ‘unexplained’ is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis being made by theprimary care professional after initial assessment of the history, examination and primary careinvestigations (if any)’. In the context of this recommendation, the primary care professionalshould confirm that the dyspepsia is new rather than a recurrent episode and excludecommon precipitants of dyspepsia such as ingestion of NSAIDs. ‘Persistent’ as used in therecommendations in the referral guidelines refers to the continuation of specified symptomsand/or signs beyond a period that would normally be associated with self-limiting problems.
The precise period will vary depending on the severity of symptoms and associated features,as assessed by the healthcare professional. In many cases, the upper limit the professional willpermit symptoms and/or signs to persist before initiating referral will be 4–6 weeks. NICE guideline: quick reference guide – dyspepsia 3 Common elements of care
● For many patients, self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken ‘as required’) may continue to be appropriate for immediate symptom relief. However, additional therapy is appropriate to manage symptoms that persistently affect patients’ quality of life.
● Offer older patients (over 80 years of age) the same treatment as younger patients, taking account of any comorbidity and their ● Offer simple lifestyle advice, including advice on healthy eating, weight reduction and smoking cessation.
● Advise patients to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee, chocolate, fatty foods and being overweight. Raising the head of the bed and having a main meal well before going to bed ● Provide patients with access to educational materials to support ● Psychological therapies, such as cognitive behavioural therapy and psychotherapy, may reduce dyspeptic symptoms in the short term in individual patients. Given the intensive and relatively costly nature of such interventions, routine provision by primary care ● Patients requiring long-term management of dyspepsia symptoms should be encouraged to reduce their dose of prescribed medication stepwise: by using the effective lowest dose, by trying as-required use when appropriate, and by returning to self- treatment with antacid or alginate therapy.
NICE guideline: quick reference guide – dyspepsia 4 Uninvestigated dyspepsia
Management flowchart for patients with uninvestigated dyspepsia Dyspepsia not
needing referral
theophyllines, bisphosphonates,steroids and NSAIDs.
advice on healthy eating, weightreduction and smokingcessation, promoting continued evidence to guide whether full-dose PPI for one month or H. pylori test and treat should be offered first. Either treatmentmay be tried first with the otherbeing offered where symptomspersist or return.
breath test, stool antigen test or,when performance has beenvalidated, laboratory-based Eradication: use a PPI,amoxicillin, clarithromycin 500mg (PAC500) regimen or a PPI,metronidazole, clarithromycin Do not re-test even if dyspepsiaremains unless there is a strongclinical need.
limited number of repeatprescriptions. Discuss the use oftreatment on an as-requiredbasis to help patients manage inadequate response to therapyit may become appropriate torefer to a specialist for a second opinion. Emphasise the benignnature of dyspepsia. Reviewlong-term patient care at least Return to self care
annually to discuss medicationand symptoms.
NICE guideline: quick reference guide – dyspepsia 5 Gastro-oesophageal reflux disease, peptic ulcer and non-ulcer dyspepsia
Management flowchart for patients with GORD Gastroesophageal
reflux disease1
Return to self care
1 GORD refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease. Patients with uninvestigated ‘reflux-like’ symptoms should be managed as patients with uninvestigated dyspepsia.
There is currently no evidence that H. pylori should be investigated in patients with GORD.
Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions. 3 Review long-term patient care at least annually to discuss medication and symptoms.
In some patients with an inadequate response to therapy or new emergent symptoms it may become appropriateto refer to a specialist for a second opinion. Review long-term patient care at least annually to discuss medication and symptoms. A minority of patients have persistent symptoms despite PPI therapy and this group remain a challenge to treat.
Therapeutic options include doubling the dose of PPI therapy, adding an H2RA at bedtime and extending thelength of treatment.
NICE guideline: quick reference guide – dyspepsia 5 Gastro-oesophageal reflux disease, peptic ulcer and non-ulcer dyspepsia
Management flowchart for patients with gastric ulcer Gastric ulcer
Periodic review6
Refer to specialist
Refer to specialist
Return to self care
secondary care
secondary care
1 If NSAID continuation is necessary, after ulcer healing offer long-term gastric protection or consider substitution to a 2 Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory-based 3 Use a PPI, amoxicillin, clarithromycin 500 mg (PAC500) regimen or a PPI, metronidazole, clarithromycin 250 mg (PMC250) regimen.
Follow guidance found in the British National Formulary for selecting second-line therapies.
After two attempts at eradication manage as H. pylori negative.
4 Perform endoscopy 6–8 weeks after treatment. If re-testing for H. pylori use a carbon-13 urea breath test. 5 Offer low-dose treatment, possibly used on an as-required basis, with a limited number of repeat prescriptions. 6 Review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide lifestyle advice. In some patients with an inadequate response to therapy it may become appropriate to refer to aspecialist. NICE guideline: quick reference guide – dyspepsia 5 Gastro-oesophageal reflux disease, peptic ulcer and non-ulcer dyspepsia
Management flowchart for patients with duodenal ulcer Duodenal ulcer
Return to self care
1 If NSAID continuation is necessary, after ulcer healing offer long-term gastric protection or consider substitution to a 2 Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory-based serology.
3 Use a PPI, amoxicillin, clarithromycin 500 mg (PAC500) regimen or a PPI, metronidazole, clarithromycin 250 mg (PMC250) 5 Follow guidance found in the British National Formulary for selecting second-line therapies.
6 Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions. 7 Consider: non-adherence with treatment, possible malignancy, failure to detect H. pylori infection due to recent PPI or antibiotic ingestion, inadequate testing or simple misclassification; surreptitious or inadvertent NSAID or aspirin use;ulceration due to ingestion of other drugs; Zollinger Ellison syndrome, Crohn’s disease.
8 Review care annually, to discuss symptoms, promote stepwise withdrawal of therapy when appropriate and provide NICE guideline: quick reference guide – dyspepsia 5 Gastro-oesophageal reflux disease, peptic ulcer and
non-ulcer dyspepsia
Management flow chart for patients with non-ulcer dyspepsia Non-ulcer
dyspepsia
Return to self care
1 Use a PPI, amoxicillin, clarithromycin 500 mg (PAC500) regimen or a PPI, metronidazole, clarithromycin 250 mg(PMC250) regimen. Do not re-test unless there is a strongclinical need.
2 Offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions. 3 In some patients with an inadequate response to therapy or new emergent symptoms it may become appropriateto refer to a specialist for a second opinion.
Emphasise the benign nature of dyspepsia. Review long-term patient care at least annually to discuss medicationand symptoms.
NICE guideline: quick reference guide – dyspepsia 6 Reviewing patient care
● Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them totry stepping down or stopping treatment*.
● A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as-required) maybe appropriate.
● Offer simple lifestyle advice, including healthy eating, weight ● Advise patients to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee,chocolate, fatty foods and being overweight. Raising the head of thebed and having a main meal well before going to bed may help somepeople.
● Routine endoscopic investigation of patients of any age presenting with dyspepsia and without alarm signs is not necessary. However, forpatients over 55, consider endoscopy when symptoms persist despiteH. pylori testing and acid suppression therapy and when patients haveone or more of the following: previous gastric ulcer or surgery,continuing need for NSAID treatment, or raised risk of gastric canceror anxiety about cancer.
● Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, inpatients aged 55 years and older with unexplained** and persistent**recent-onset dyspepsia alone, an urgent referral for endoscopy shouldbe made. * Unless there is an underlying condition or comedication requiring continuing ** In the referral guidelines for suspected cancer (NICE Clinical Guideline no. 27), ‘unexplained’ is defined as ‘a symptom(s) and/or sign(s) that has not led to adiagnosis being made by the primary care professional after initial assessmentof the history, examination and primary care investigations (if any)’. In thecontext of this recommendation, the primary care professional shouldconfirm that the dyspepsia is new rather than a recurrent episode andexclude common precipitants of dyspepsia such as ingestion of NSAIDs.
‘Persistent’ as used in the recommendations in the referral guidelines refersto the continuation of specified symptoms and/or signs beyond a period thatwould normally be associated with self-limiting problems. The precise periodwill vary depending on the severity of symptoms and associated features, asassessed by the healthcare professional. In many cases, the upper limit theprofessional will permit symptoms and/or signs to persist before initiatingreferral will be 4–6 weeks. NICE guideline: quick reference guide – dyspepsia 7 Heliocobacter pylori: testing and eradication
● H. pylori can be initially detected using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where itsperformance has been locally validated.
● Re-testing for H. pylori should be performed using a carbon-13 urea breath test. (There is currently insufficient evidence to recommend thestool antigen test as a test of eradication.) ● Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance.
● For patients who test positive, provide a 7-day twice-daily course of treatment consisting of a full-dose PPI, with either metronidazole 400mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin500 mg.
● For patients requiring a second course of eradication therapy, a regimen should be chosen that does not include antibiotics givenpreviously (see the British National Formulary for guidance).
NICE guideline: quick reference guide – dyspepsia Implementation
Local health communities should review their existing practice in the treatment andmanagement of dyspepsia against this guideline. The review should consider theresources required to implement the recommendations in Section 1 of the NICEguideline, the people and processes involved and the timeline over which fullimplementation is envisaged. It is in the interests of patients that the implementationtimeline is as rapid as possible.
Relevant local clinical guidelines, care pathways and protocols should be reviewed inthe light of this guidance and revised accordingly.
Further information
Quick reference guide
This quick reference guide to the Institute’s guideline on managing dyspepsiacontains the key priorities for implementation, the guidance, and notes onimplementation. NICE guideline
The NICE guideline on dyspepsia contains the following sections: Key priorities forimplementation; 1 Guidance; 2 Notes on the scope of the guidance;3 Implementation in the NHS; 4 Research recommendations; 5 Other versions of thisguideline; 6 Related NICE guidance; 7 Review date. The NICE guideline also givesdetails of the scheme used for grading the recommendations, GuidelineDevelopment Group, the Guideline Review Panel, and technical details on criteria foraudit. The NICE guideline is available on the NICE website atwww.nice.org.uk/CG017NICEguideline Full guideline
The full guideline includes the evidence on which the recommendations are based, inaddition to the information in the NICE guideline. It is published by the Centre forHealth Services Research, University of Newcastle upon Tyne. It is available fromwww.nice.org.uk/CG017fullguideline and on the website of the National ElectronicLibrary for Health (www. nelh.nhs.uk).
Information for the public
NICE has produced information describing this guidance for people with dyspepsia,their advocates and carers and the public. This information is available in English andWelsh from the NICE website (www.nice.org.uk/CG017publicinfo). Printed versionsare also available – see below for ordering information.
Review date
The process of reviewing the evidence is expected to begin 4 years after the date ofissue of this guideline. Reviewing may begin earlier than 4 years if significantevidence that affects the guideline recommendations is identified sooner. Theupdated guideline will be available within 2 years of the start of the review process.
NICE guideline: quick reference guide – dyspepsia National Institute for
Clinical Excellence
Ordering information
National Institute for
Copies of this quick reference guide can be obtained from the NICE website at Clinical Excellence
www.nice.org.uk/CG017 or from the NHS Response Line by telephoning 0870 1555 455and quoting reference number N0732 for the booklet version and N0689 for the poster version. Information for the public is also available from the NICE website or from the NHS Response Line (quote reference number N0690 for the English version and N0691 for a version in English and Welsh).

Source: http://www.refluxoinfo.com.pt/downloads/NICEguideline.pdf