Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page

Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page
Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page
Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page
Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page
Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page
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Transcript of Enhanced Primary Care Pathway: DYSPEPSIA .Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page

Enhanced Primary Care Pathway: DYSPEPSIA Dec 2016 - Page 2/6

EnhancedPrimaryCarePathway:DYSPEPSIA

1.Focusedsummaryofdyspepsiarelevanttoprimarycare

Dyspepsia refers to a symptom complex of gastroduodenal origin, characterized by epigastric pain ordiscomfortthatmaybetriggeredbyeatingandmaybeaccompaniedbyasenseofabdominaldistentionorbloatingandlossofappetite.TheRomeIIIcommitteeonfunctionalGIdisordersdefinesdyspepsiaasoneormoreofthefollowingsymptoms:

Postprandialfullness(postprandialdistresssyndrome) Epigastricpainorburning(epigastricpainsyndrome) Earlysatiety

Othersymptomssuchasbelchingandnauseamayoccur.Thereisfrequentoverlapbetweendyspepsiaandheartburn,whichtypifiesgastroesophagealreflux(GERD).Irritablebowelsyndromealsooverlapswithfunctional dyspepsia, where the predominant symptom complex includes bloating and relief afterdefecation. Biliary tract pain should also be considered, the classic symptom description being post-prandial(worsewithfattymeals)deep-seatedrightupperquadrantpainthatbuildsoverseveralhoursandthendissipates.Dyspeptic symptoms in the general population are common: estimates as high as 30% of individualsexperiencedyspepticsymptoms,whilefewseekmedicalcare.Althoughthecausesofdyspepsiaincludeesophagitis,pepticulcerdisease,Helicobacterpyloriinfection,celiacdisease,andrarelyneoplasia,most patientswith dyspepsia have no organic disease, with a normal battery of investigationsincludingendoscopy.Themechanismofthissymptomcomplexis incompletelyunderstood,but likelyinvolvesvisceralhypersensitivity,alterationsingastricaccommodationandemptyingandalteredcentralpainprocessing.2.Checklisttoguideyourin-clinicreviewofthispatientwithdyspepsiasymptoms

o Absenceofredflagfeatures(weightloss,anemia,irondeficiency,dysphagia,vomiting,age>50ywithnewsymptoms)

o Negativeureabreathtest(mustbedoneoffPPI,H2-receptorantagonists,antacidsforminimumof3days,andoffallantibioticsforminimumof4weeks)

o Lifestylemodificationshavebeendiscussedandpatienthasincorporatedtheseintotheirinitialtreatmentplan(smallermeals,avoidanceofidentifiedfoodtriggers,appropriateweightloss,elevationofheadofbed,smokingcessation)

o PatientadherenttotrialofPPI(canstartoncedailythenescalatetotwicedaily,30minutesbeforebreakfastandsupperforminimumof8weeks)

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EnhancedPrimaryCarePathway:DYSPEPSIA3.Linkstoadditionalresourcesforphysiciansandpatients

CalgaryGIDivisionhttp://www.calgarygi.com

MyHealth.Alberta.cahttps://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=tm6322

CanadianDigestiveHealthFoundationhttp://www.cdhf.ca/en/disorders/details/id/20

UpToDateBeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/upset-stomach-functional-dyspepsia-in-adults-beyond-the-basics?source=search_result&search=dyspepsia+patient+info&selectedTitle=2~150

AlbertaHealthyLivingProgramwww.ahs.ca/info/cdmcalgaryzone.asp

4.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofdyspepsia,frombothGastroenterologyandPrimaryCareliterature:

Miwaetal.Evidence-basedclinicalpracticeguidelinesforfunctionaldyspepsia.JGastroenterol.50:125-39,2015

Ansarietal.Initialmanagementofdyspepsiainprimarycare:anevidence-basedapproach.BrJGenPract.63:498-9,2013

Diagnosis and treatment of chronic undiagnosed dyspepsia in adults. Toward Optimized Practicehttp://www.topalbertadoctors.org/cpgs/3294128

AmericanSocietyofGastrointestinalEndoscopyStandardsofPracticeCommittee.Theroleofendoscopyindyspepsia.GastrointestEndosc66:1071-5,2007

Thefollowingisabest-practiceclinicalpathwayformanagementofdyspepsiaintheprimarycaremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:

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FlowDiagram:DYSPEPSIADiagnosisandManagement-ExpandedDetail1. Establishthediagnosisofdyspepsiaasdefinedabovethroughhistoryandphysicalexamination,

excludingworrisomefeaturesorredflags.Inthepresenceofanyredflags,referraltoGastroenterologyforconsiderationofurgentendoscopicinvestigationisrecommended,eventhoughthepredictivevalueofthesefeaturesissomewhatlimited.

2. Reviewofthepatientsmedicationprofileshouldbeundertakentotrytoidentifyobviousculprits

suchasASA/NSAIDs/COX-2inhibitors,steroids,bisphosphonates,calciumchannelblockers,antibiotics,ironormagnesiumsupplements.Anyneworrecentlyprescribedmedication,overthecounterorherbal/naturalproductmaybeimplicatedasvirtuallyallmedicationscancauseGIupsetinsomepatients.

3. BaselineInvestigationsaimedatidentifyingconcerningfeaturesorclearetiologies:

CBCandferritin Anti-tissuetransglutaminasehas>95%sensitivitytoruleoutceliacdisease ALT,ALP,GGT,andlipase,aimedatidentifyingahepatobiliaryorpancreaticsourceof

pain Ifpainisconsistentwithbiliarycolicorliverenzymesorlipaseareabnormalorthereis

apalpableabdominalmass,obtainatrans-abdominalultrasound. UpperGIseriesmaybeconsidered,butislowyieldforrelevantfindings,asis

endoscopy4. TestandtreatHelicobacterpyloribyureabreathtest(UBT).Thisstrategyisbasedonevidencethat

somedyspepticpatientsarecolonizedbyH.pyloriandwillhaveunderlyingpepticulcerdiseaseorgastritis.

IftheUBTispositive,2016Canadianconsensusguidelinesnowrecommendquadrupletherapyregimens(seetablebelow).

Tripletherapy(PPI+clarithromycin+amoxicillinormetronidazole)isnolongerrecommended,asstudiesofHpisolatesinCanadasuggest25-30%areresistanttometronidazoleand15-20%areresistanttoclarithromycin.

Withtheexceptionoftherifabutin-basedregimen,alltreatmentsforHpshouldbe14daysduration.

ALWAYSdiscusswithyourpatientthepossibleminororseriousadverseeffectsofantibiotics.SeeEnhancedPrimaryCarePathwayH.Pyloriforadditionaldetails,whichincludesusefulpatientinformationhandouts.

Iffailsthirdlinetherapy,considerreferraltoGastroenterologyordiscussionviaSpecialistLinkbeforeproceedingtoRifabutin-basedtreatment.

5. Lifestylemodification.Therearefewstudiestosupportspecificdietaryrecommendations,buta

trialofvariousdietaryexclusionsundertheguidanceofanutritionistorregistereddieticianmaybehelpful,includingavoidanceoflactoseandfoodshighinfructose(FODMAPs).

6. Empiricanti-secretorymedicationtrial.IntheabsenceH.pyloriinfectionorcontinuedsymptoms

despitesuccessfulH.pylorieradication,atrialofstandarddosePPIfor4-8weeksmaybenefitsomepatients.PPIsarefavouredoverH2-receptorantagonists.Initialtherapyshouldbeoncedaily,30minbeforebreakfast.Ifthereisnosignificantsymptomaticimprovementafter4weeks,stepuptoBID

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dosingorswitchtoanotherPPI.Ifsymptomsarethencontrolled,itisadvisabletotitratedowntothelowesteffectivedose.

7. Trialofmotilityagents.Althoughdelayedgastricemptyingcanbedemonstratedin30-80%of

patientswithdyspepsia,gastricemptyingstudiesarenotpartofroutineinvestigationofdyspepsia.Prokineticagentsimprovegastricemptying,andsomepatientsmayfindclinicalbenefit.Domperidonecanbeusedinescalatingdoses,suggeststartingat5mgTID-AC,upto10mgPOQIDasa2-4weektrial.

Thereareinsufficientdatatorecommendtheroutineuseofbismuth,antacids,simethicone,misoprostol,anti-cholinergics,anti-spasmodics,TCAs,SSRIs,herbaltherapies,probioticsorpsychologicaltherapiesinfunctionaldyspepsia.However,thesetherapiesmaybeofbenefitinsomepatients,andthusatrialwithassessmentofresponsemaybereasonableandisunlikelytocauseharm.2016CanadianAssociationofGastroenterologyGuidelinesforTreatmentofH.pylori

First Round

CLAMET Quad for 14 days PPI standard dose BID Clarithromycin 500mg BID Amoxicillin 1000mg BID Metronidazole 500mg BID

OR

BMT Quad for 14 days PPI standard dose BID Bismuth subsalicylate 524mg QID Metronidazole 375mg QID Tetracycline 500mg BID

Second Round

If CLAMET Quad was used as initial treatment, then use BMT Quad for second round If BMT Quad was used as initial treatment, then use CLAMET Quad or consider Levo-Amox

Third Round Fourth Round

Levo-Amox for 14 days PPI standard dose BID Amoxicillin 1000mg BID Levofloxacin 250 mg BID

Rif-Amox for 10 days PPI standard dose BID Rifabutin 150mg BID Amoxicillin 1000mg BID

IMPORTANT: Rif-Amox should only be considered after failure or intolerance of other regimens. Rifabutin has rarely been associated with potentially serious myelotoxicity. The pros and cons of giving fourth-line therapy should be decided on a case-by-case basis.

Standard doses of PPIs are: omeprazole 20mg, rabeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg, esomeprazole 40mg, and dexlansoprazole 30mg