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VIEWS: 25 PAGES: 8

									   N P S NEWS                                                                                                       14




                                                                                                                                          2001
                                                                                                                                                      ISSN 1441-7421 February 01
 National Prescribing Service Newsletter


                                                                                                                  Inside




                                                                                                                                           v
                                                                                                                  Lifestyle modifications
Approximately 25% of the adult population              gastric or oesophageal cancer (less than
in Western society experience dyspeptic                2% of cases). People who have no definite                   Managing GORD and
symptoms (pain or discomfort centred in the            structural or biochemical explanation for                  non-ulcer dyspepsia
upper abdomen) at least monthly while 5%               their symptoms are considered to have
experience daily symptoms.1                            non-ulcer dyspepsia.2                                      To treat or not to treat -
The main pathological causes of dyspepsia              In this issue we focus on using lifestyle                  Should patients with non-
are gastric or duodenal ulcer, gastro-                 measures and medication to manage GORD                     ulcer dyspepsia be treated
oesophageal reflux disease (GORD) and                   and non-ulcer dyspepsia.                                   for H. pylori infection?

                                                                                                                  Your questions answered -
                                                                                                                  Could your patient’s
                                                                                                                  epigastric pain be
                                                                                                                  drug-related?
GORD and non-ulcer dyspepsia                                                                                      Case study 13

- symptoms and risk factors

The predominant symptom that differentiates GORD from                        (particularly significant life events in the past year) and psychiatric
non-ulcer dyspepsia is typically heartburn or acid regurgitation,            illness strongly correlated with dyspepsia and GORD-like symptoms.4
although epigastric pain may often be present in people
                                                                             Risk factors for development of GORD may include obesity,
with GORD and non-ulcer dyspepsia.3
                                                                             consumption of more than seven standard alcoholic drinks
Many population studies have attempted to correlate lifestyle                per week and smoking.5
factors such as diet, alcohol consumption and smoking with
                                                                             Risk factors for development of non-ulcer dyspepsia are
the occurrence of dyspeptic symptoms, but the results of these
                                                                             use of aspirin or nonsteroidal anti-inflammatory drugs
studies are sometimes conflicting and difficult to interpret.
                                                                             and smoking, but not drinking alcohol or coffee.4,6
A large international study found that psychological stress




Case study inside - see page 5                                               NPS satellite broadcast
For GPs                                                                      Managing dyspepsia: Tuesday 27 March 2001
The case study in this issue of NPS News is the last case study
eligible for inclusion in the current PIP period, 1 May 2000_30 April
2001. If GPs wish to include it as one of their Quality Prescribing
Initiative activities for this period, please complete and return to NPS
by 28 February 2001.

For pharmacists
Pharmacists are also invited to complete and return the case study
in this issue. Participants will receive an aggregate of responses plus      Information on the next NPS satellite broadcast will be forwarded
expert feedback on the topic.                                                to all GPs and pharmacists shortly. Information is also available
                                                                             on the Events page of our website: http://www.nps.org.au.
                                                                             For registration details, contact Health Television Network:
                                                                             phone (02) 9450 0944
                                                                             fax       (02) 9450 1220




                                 National Prescribing Service Limited ACN 082 034 393
            – an independent, non-profit, educational organisation supporting quality prescribing in Australia.
Lifestyle modifications
Clinical practice shows positive results for some
The evidence to support lifestyle modifications in managing            preparations 10–20 ml orally as required or antacid plus
GORD and non-ulcer dyspepsia is limited and at times                  alginate preparations 10–20 ml orally up to four times
conflicting.                                                           daily are recommended.1
Clinical practice, however, suggests that some patients,         According to two studies, elevation of the head of the bed
especially those who experience occasional or intermittent       did not decrease the frequency of reflux episodes in people
episodes of GORD, can improve their quality of life by:          with moderate to severe GORD.2,3 Another study, however,
                                                                 showed reduced symptoms and improved endoscopic
   not eating large or fatty meals or foods which are
                                                                 appearance.4
   known to precipitate symptoms (eg chocolate, spices,
   peppermints)                                                  Although there is an association between obesity and
   not eating two hours before lying down or going               GORD, one small study found that GORD symptoms
   to bed                                                        in obese patients did not abate after weight reduction.5
   limiting alcohol consumption                                  It may be reasonable for patients to discontinue taking
   stopping smoking                                              drugs that can exacerbate symptoms, unless these are
   trying an antacid when symptoms occur. While chewable         particularly indicated. These drugs include selective COX-2
   tablets are more convenient, liquid preparations are          inhibitors, nonsteroidal anti-inflammatory drugs and calcium
   more effective. Magnesium plus aluminium hydroxide            channel blockers.




               Your questions answered
               Based on questions health professionals have asked the NPS Therapeutic
               Advice and Information Service (TAIS). Contact TAIS on 1300 138 677 for
TAIS           answers to your questions on medicines.

Could your patient’s epigastric pain                           dyspepsia is listed as a possible adverse effect in the product
be drug-related?                                               information for some but not all calcium channel blocker
Calcium channel blockers and GORD                              preparations available in Australia.

Although the target site of action of the calcium channel      However, a recent unpublished study conducted in Western
blockers is cardiac and vascular smooth muscle, other smooth   Australia suggests that the problem may be much more
muscle are not immune to their effects. Calcium channel        common than previously recognised. In this study of patients
blockers may decrease gastric motility and reduce lower        who were treated with a calcium channel blocker for
oesophageal sphincter pressure. This may result in reflux       hypertension (those with a history of ischaemic heart disease
of gastric acid into the oesophagus and consequent             were excluded), reflux related symptoms developed in 85
dyspeptic symptoms including epigastric pain.                  (35.3%) of 241 previously asymptomatic patients.

Interestingly, nifedipine† has been used to treat achalasia*   Well designed studies are needed to clarify the role of calcium
and also to relax the oesophageal body in patients with        channel blockers in GORD. However, health practitioners
foreign bodies lodged in the oesophagus. Verapamil† has also   should keep it in mind as a potential cause of GORD
been used. Diltiazem† appears to have a lesser effect—it       in previously asymptomatic patients.
decreases oesophageal peristalsis but may not reduce lower     † Not approved indications.
oesophageal sphincter pressure.
                                                               * Failure of normal relaxation of the upper or lower oesophageal sphincter
There are only a couple of case reports of calcium channel       resulting in functional obstruction.

blocker induced GORD in the published literature, and
                 Prescribing pointers
   v
                 Managing GORD
The management plan for patients with GORD should reflect the severity of symptoms.1,2

The aim of treatment is to provide symptomatic relief (and ulcer          Maintenance acid suppression with PPIs should be reserved
healing where appropriate) with the first effective treatment used         for patients with erosive or frequently relapsing disease.3,7
at the lowest effective dose.                                             This strategy allows improved targeting of intermittent
                                                                          and maintenance treatments.
Potential management strategies are:1,3
   Lifestyle modification with intermittent use of antacids.               Safety concerns with cisapride
   Consider patients' regular use of antacids as a prompt                 The role of cisapride in treating GORD is unclear. Although it is an
   to reassess their treatment and prescribe further therapy              effective form of treatment for GORD, it can produce prolonged
   (see below) along with non-drug measures.                              QT intervals and has the potential to cause cardiac arrhythmias.
   H2 antagonists:
                                                                          A recent reassessment of the benefit/risk profile of cisapride has
   ranitidine 150 mg or famotidine 20 mg or cimetidine 400 mg
                                                                          led to changes to the approved indications for its use in adults.
   or nizatidine 150 mg twice daily (doubling the dose may be
                                                                          These are now limited to treating "severe reflux oesophagitis
   tried if satisfactory control is not achieved—NB this higher
                                                                          where other available treatment including acid suppression with
   dose has not been approved by the Therapeutic Goods
                                                                          proton pump inhibitor drugs has failed", and "gastroparesis
   Administration but has been successfully used in clinical trials).
                                                                          where the diagnosis has been made or confirmed by a specialist
   Proton pump inhibitors (PPIs): omeprazole 20 mg or lansoprazole        physician".
   30 mg or pantoprazole 40 mg orally daily (doubling the dose
   may be tried if satisfactory control is not achieved).                 The listing for cisapride on the Pharmaceutical Benefits Scheme
                                                                          (PBS) is restricted on authority for treating gastroparesis diagnosed
Reassessment should occur after four weeks4,5 because those               or confirmed by a consultant physician. Because of a lack of
unresponsive to H2 antagonists are unlikely to respond with               clinical data, the Pharmaceutical Benefits Advisory Committee
continued therapy, while most will have responded to PPIs                 (PBAC) does not support subsidising cisapride in patients who
by this time.4                                                            have not responded to PPIs.
PPIs provide more complete oesophagitis healing and faster
symptom relief compared with H2 antagonists, although the                 Amendment to the PBS
evidence is based on short-term drug efficacy rather than                  All PPIs effectively treat reflux oesophagitis. However, the PBS
long-term disease management.4,6 Since GORD is a chronic                  currently requires authority approval prior to prescribing PPIs,
relapsing condition, long-term or maintenance treatment                   and restricts their use in the treatment of GORD to patients with
is often necessary.                                                       severe refractory ulcerating oesophagitis proven by endoscopy.

In the large group of patients with endoscopy-negative reflux              Recently the PBAC recommended an amendment to this PBS
(no ulceration of the oesophagus), PPIs can relieve symptoms              requirement for one of the PPIs—pantoprazole—transferring it
faster and more reliably than less potent therapy. Intermittent           to a restricted benefit listing for the treatment and maintenance
courses of two to four weeks' duration when symptoms recur                of reflux oesophagitis and removing the need for endoscopic
have been shown to be both effective3,7 and cost-effective3,8;            proof of ulceration9; this should take effect from May 2001.
doses used are those that initially controlled symptoms.                  The PBAC considers the cost-effectiveness of this treatment
Patients who respond quickly to initial treatment are more likely         in gastro-oesophageal disease acceptable at the price negotiated
to be controlled successfully with intermittent therapy.7                 with the pharmaceutical company.




Managing non-ulcer dyspepsia
The majority of people investigated for dyspepsia with endoscopy        A large number of studies have suggested that cisapride
do not have peptic ulcer disease, reflux oesophagitis or gastric         is the treatment of choice for patients with non-ulcer dyspepsia.
cancer; they have non-ulcer (or functional) dyspepsia. The treatment    However these studies are flawed methodologically,10 and current
approach is less clear than for GORD as the cause is not understood     PBS restrictions will not allow prescribing of cisapride for this
and treatment is often unsatisfactory.                                  condition unless the patient has confirmed gastroparesis.
There is poor evidence that any empiric therapy is effective because    Further evidence is required on the efficacy of domperidone
of a significant placebo response in trials. Up to 60% of people
                                          10
                                                                        and metoclopramide in non-ulcer dyspepsia.10
improve without intervention, making drug use and assessment
                                                                        A four week trial of either acid suppression or a motility stimulant
of treatment difficult.
                     10

                                                                        is recommended for patients with uninvestigated dyspepsia.
Some patients have reflux-like symptoms and respond to GORD              If the patient fails to respond, a switch to the alternative drug class
treatment, although antacids provide little benefit.
                                                  10,11
                                                                        is suggested, stopping for investigation after another four weeks
                                                                        if symptoms persist.  12,13

There is no evidence that acid suppression with Proton pump
inhibitors (PPIs) is more effective than with H2 antagonists.
To treat or not to treat
Should patients with non-ulcer dyspepsia                        Cost-effectiveness
be treated for Helicobacter pylori infection?                   H. pylori eradication for non-ulcer dyspepsia is relatively
Professor Nicholas Talley says “Overall, the                    expensive compared to traditional aluminium-based
                                                                antacids for a small incremental benefit, at least over
benefits of H. pylori eradication probably
                                                                the short-term. However in the longer term, and taking
outweigh the risks, and this is a reasonable                    account of prescriptions for PPIs and H2 antagonists,
option for patients with non-ulcer dyspepsia                    it may prove to be a cost-effective option for the
who are infected. However, most will not                        community and the patient.5
have their symptoms relieved by eradication
                                                                Non-ulcer dyspepsia is not currently an approved
therapy.”
                                                                indication for H. pylori eradication therapy on the PBS,
About H. pylori                                                 and the cost of a private prescription would be around
                                                                $100 per patient.
    In Australia, approximately one-third of the population
    are infected with H. pylori. However, the majority
    of these people are asymptomatic and untroubled
    by the infection.1
                                                                 What’s what
    All patients with H. pylori infection have chronic
    gastritis histologically.1
                                                                 H2 Antagonists
    Most people with the infection are over the age              cimetidine:
    of 40; fewer than 10% of children currently
                                                                 Cimehexal® Magicul® SBPA Cimetidine® Sigmetadine®
                                                                          ‚        ‚                ‚            ‚
    have H. pylori infection.1
                                                                 Tagamet®
    The risk of reinfection after successful treatment
                                                                 famotidine:
    in adults is very low (< 1% per year).1
                                                                 Amfamox® Pepcid® Pepcidine®
                                                                        ‚       ‚
Non-ulcer dyspepsia and H. pylori                                nizatidine:
Approximately 30% to 50% of patients with non-ulcer              Tazac®
dyspepsia are infected with H. pylori and have histological
gastritis. It remains debatable whether these patients           ranitidine:
should have their H. pylori infection treated.1                  Ausran® DBL Ranitidine® Rani 2® Ranihexal® Ranoxyl®
                                                                       ‚               ‚       ‚          ‚        ‚
                                                                 SBPA Ranitidine® Zantac® Zantac Relief®
                                                                                ‚        ‚
Treating this group may prevent them having future peptic
ulcer disease (based on recent clinical trials, about 5% of      Proton Pump Inhibitors
patients with non-ulcer dyspepsia develop a peptic ulcer
on follow-up over 12 months).2                                   lansoprazole:
                                                                 Zoton®
Furthermore, there is limited albeit conflicting evidence
that about 1 in 15 patients with non-ulcer dyspepsia             omeprazole
will achieve symptomatic relief from H. pylori eradication.      Acimax® Losec® Maxor®
                                                                       ‚      ‚
This is derived from a meta-analysis that found 28% of
patients treated with placebo and 36% treated with               pantoprazole:
eradication therapy were either free of dyspepsia                Somac®
symptoms or much improved after one year.3
                                                                 rabeprazole:
There is also some evidence that patients with H. pylori         Pariet® (registered but as yet unmarketed)
gastritis progress more rapidly to gastric atrophy in the
body of the stomach in the setting of potent acid                Motility Stimulants
suppression. Some have recommended this group
                                                                 cisapride:
have the infection eliminated.4
                                                                 Prepulsid® Prepulsid Forte®
                                                                          ‚
What about risks?                                                domperidone:
Potential disadvantages of the treatment include antibiotic      Motilium®
side-effects which are common but rarely serious.
                                                                 metoclopramide:
Concerns have been raised about treatment and the
                                                                 Maxolon® Pramin®
                                                                        ‚
possible development of reflux oesophagitis, but based
on most recent data this appears to be unusual.2
There is no convincing evidence that eradication of H. pylori
infection increases the risk of gastro-oesophageal cancer.
Clarification
NPS News 12: Hormone Replacement Therapy (HRT)
Breast cancer risk and HRT                                         Because of these variables the example given—ie a background
                                                                   incidence of breast cancer of 3.8% at 60 years increases to
Breast cancer risk increases by 2.3% each year for current
                                                                   4.0% in women who used HRT for five years starting at age
or recent users (ie those who ceased use one to four years
                                                                   50—does not equate with an increase of 2.3% each year.1,2,3
previously) of HRT. There is no significant excess risk of breast
cancer five or more years after stopping HRT.                       Condensing the information created some confusion.
The background incidence of breast cancer increases with age.
                                                                   Your questions on HRT
Among never users of HRT the relative risk of breast cancer
increases by 2.8% for each year older at menopause. The            The article cited a small study that “found 50% of
longer the duration of use and the older women are when            patients taking 100mcg of norethisterone combined with
they use HRT, the larger the cumulative excess numbers             0.625–1.25mg conjugated oestrogens showed proliferative
of breast cancer diagnosed.                                        changes. Whereas 8% of patients taking 375mcg or 700mcg
                                                                   and only 4% of patients taking 2.5mg norethisterone showed
Therefore, whilst overall the risk increases by 2.3% each year     proliferative changes.”
(for current or recent users of HRT), the magnitude of the
increased risk of breast cancer with HRT use varies depending      The last line should read, “Whereas 8% of patients taking
on the age when HRT is used and the duration of use.               350mcg or 700mcg and 3% of patients taking 2.5mg
                                                                   norethisterone showed proliferative changes.”




Case study instructions
Case study 13: Management of Dyspepsia


  For doctors and pharmacists
  Doctors and pharmacists are invited to submit responses to the enclosed case study for collation.
  Please answer the questions on the enclosed form and return to NPS.
  One side of the form is for use by doctors; the other for pharmacists.
  We will send you expert commentary on the case study and the aggregated responses which will provide a snapshot
  of how your colleagues responded to the case.

  For GPs
  This case study can be used by GPs to claim Practice Incentives Program (PIP) points if all questions are completed.
  This is the final case study for inclusion in the current PIP period.
  If you wish this case study to count towards PIP you will need to quote your provider and prescriber numbers
  on the case study form. Please call NPS if you require further details.

  Case Study 13
  Mr Green, a 42 year old man, presents to you with a three month history of intermittent non-specific epigastric discomfort
  after eating. There are no obvious symptoms of reflux such as heartburn. His job involves significant stress. He has a
  moderate alcohol intake, again on an intermittent basis. He is a non-smoker and his weight is steady. He thinks the
  discomfort may be worse for a day or two after drinking more than usual. He has no other symptoms. There is nothing
  of relevance in either his personal or family history. He has not taken any medication for the discomfort and takes
  no regular medications.

  Sending in the forms
  Closing date for submission to NPS: Wednesday 28 February 2001

  Send the completed case study to:
  NPS Level 1/31 Buckingham Street SURRY HILLS NSW 2010 or fax to: (02) 9699 5155
Contributing Authors                                   Reviewers
Dr Peter Katalaris, Consultant                         Dr Nick Carr, General Practitioner                     Ms Simone Rossi, Australian Medicines
Gastroenterologist, Concord Hospital,                                                                         Handbook
                                                       Prof Richard Day, Clinical Pharmacology,
Sydney NSW
                                                       St Vincent’s Hospital, Sydney NSW                      Professor Neville Yeomans, University of
Nicholas J Talley MD, PhD                                                                                     Melbourne, Dept of Medicine, Western
                                                       Ms Jan Donovan, Consumer
Professor of Medicine, Nepean Hospital,                                                                       Hospital, Footscray Victoria
Sydney NSW                                             Dr John Dowden, Australian Prescriber
                                                                                                              For details on contributing authors and
                                                       Prof John Murtagh, Royal Australian                    reviewers and any declarations of interest
                                                       College of General Practitioners                       please contact NPS on (02) 9699 4499.
                                                       Ms Susan Parker, AstraZeneca Pty Ltd




References
GORD and non-ulcer dyspepsia                           Prescribing Pointers                                   To treat or not to treat
- symptoms and risk factors                            1. Therapeutic Guidelines: Gastrointestinal, 2nd ed,   1. AGI 3rd Edition 1999. Helicobacter pylori:
1. van Pinxteren B, et al. In: The Cochrane Library,      1998/99.                                               Guidelines for Healthcare Providers.
   Issue 3, 2000. Oxford: Update Software.             2. Gastroenterological Society of Australia. 1996      2. Blum AL, Talley NJ, O’Morain C, et al. NEJM
2. Talley NJ, et al. Gastroenterology                     guidelines: Gastro-oesophageal reflux disease in       1998;339:1875-81.
   1998;114(3):582–95.                                    adults.                                             3. Moayyedi P, Soo S, Deeks J, et al. BMJ
3. Talley NJ, et al. Aliment Pharmacol Ther            3. Australian Medicines Handbook 2000.                    2000;321:659-64.
   1999;13(9):1135–48.                                 4. Veldhuyzen van Zanten SJO, et al. Can Med           4. Kuipers EJ, Lundell L, Klinkenberg-Knol EC,
4. Stanghellini V, Scand J. Gastroenterol Suppl           Assoc J 2000;162(12 Suppl)S3–S23.                      et al. NEJM 1996:334:1018-22.
   1999;231:29–37.                                     5. British Society of Gastroenterology. Dyspepsia      5. Moayyedi P, et al. In: The Cochrane Library,
5. Locke GR, et al. Am J Med 1999;106:642–49.             management guidelines. London: The Society,            Issue 3, 2000. Oxford: Update Software.
                                                          1996.
6. Nandurkar S et al. Arch Intern Med
                                                       6. van Pinxteren B, et al. In: The Cochrane Library,
                                                                                                              Breast cancer risk and HRT
   1998;158(13):1427–33.
                                                          Issue 3, 2000. Oxford: Update Software.             1. Collaborative group on hormonal factors
Lifestyle modifications                                7. Bardhan KD, et al. BMJ 1999;318:502–7.                 in breast cancer. Lancet 1997;350:1047–59.

1. Therapeutic Guidelines: Gastrointestinal,           8. Gerson LB, et al. Am J Gastroenterol 2000;          2. Schairer C, et al. JAMA 2000;283:485–491.
   2nd ed, 1998/99.                                       95(2):395–407.                                      3. Ross RK, et al. J Natl Cancer Inst
2. Hamilton JW, et al. Dig Dis Sci                     9. Commonwealth Dept Health and Aged Care.                2000;92:328-332.
   1988;33(5):518–22.                                     Positive recommendations made by the PBAC           Further references for all articles including Your
3. Johnson LF, DeMeester TR. Dig Dis Sci                  in December 2000.                                   Questions Answered are available upon request.
   1982;26:673–678.                                       http://www.health.gov.au/haf/docs/pbacred.htm

4. Harvey RF, et al. Lancet 1987;2(8569):1200–3.       10. Soo S, et al. In: The Cochrane Library, Issue 3,
                                                           2000. Oxford: Update Software.
5. Kjellin A, et al. Scand J Gastroenterol
   1996;31(11):1047–51.                                11. Fisher RS, Parkman HP. New Engl J Med
                                                           1998;339:1376–81.
                                                       12. Anon. Gastroenterology 1998;114:579–81.
                                                       13. Talley NJ, et al. Aliment Pharmacol Ther
                                                           1999;13(9):1135–48.




                  The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence.
                                          Any treatment decisions based on this information should be made
                                         in the context of the individual clinical circumstances of each patient.



                                                                     N P S
                                                          National Prescribing Service Limited



                 Our goal To improve health outcomes for Australians through prescribing that is : v safe v effective v cost - effective
                  Our programs To enable prescribers to make the best prescribing decisions for their patients, the NPS provides:
                                                v information v education v support v resources

                                            Level 1 / 31 Buckingham Street, Surry Hills NSW 2010
                         Phone: 02 9699 4499 l Fax: 02 9699 5155 l email: info@nps.org.au l net: http://www.nps.org.au
 Case study 13: Management of dyspepsia                                    NPS Office use only
 For Pharmacists                                                           00CS25

 Mr Green, a 42 year old man, presents to you with a three month history of
 intermittent non-specific epigastric discomfort after eating. There are no obvious
 symptoms of reflux such as heartburn. His job involves significant stress. He has a
 moderate alcohol intake, again on an intermittent basis. He is a non-smoker and his
 weight is steady. He thinks the discomfort may be worse for a day or two after drinking
 more than usual. He has no other symptoms. There is nothing of relevance in either his
 personal or family history. He has not taken any medication for the discomfort and
 takes no regular medications.


(Doctors , see reverse for questions)


1. What, if any, additional questions would you ask the patient?                                                  d) What advice (if any) would you provide?
                                                                                                                  i) for drug therapy:




2. Would you refer the patient to a doctor at this time? □ yes □ no
                                                                                                                  ii) other (eg lifestyle advice):

3. Would you recommend an over-the-counter medication at this presentation?
  □ yes □ no, If no, go to question 4
  If yes,
  a) please specify your choice:
                                                                                                                4. If you chose not to recommend drug therapy,
                                                          ___________________
                                                           ___________________
  Drug _________________________________________ Strength ___________________ Frequency ___________________
                                                                                                                  a) please explain why not:
  Drug _________________________________________ Strength _____________________ Frequency ___________________
  b) When would you expect to see benefit from the drug therapy used (if any)?


  c) When would you review this therapy/consider referral to doctor?                                              b) what advice (if any) would you provide?




                                                                                                                  Adapted from a case study developed by the National Preferred Medicines Centre Inc., Wellington, New Zealand.




    Sending in the forms                                  NPS Level 1/31 Buckingham St                                                                     N P S
    Closing date for submission 28 February 2001.         SURRY HILLS NSW 2010
    Send the completed case study to:                     or fax to:(02) 9699 5155                                                             National Prescribing Service Limited
 Case study 13: Management of dyspepsia                          NPS Office use only
 For Doctors                                                     00CS25
 Mr Green, a 42 year old man, presents to you with a three month history of
 intermittent non-specific epigastric discomfort after eating. There are no obvious
 symptoms of reflux such as heartburn. His job involves significant stress. He has a
 moderate alcohol intake, again on an intermittent basis. He is a non-smoker and his
 weight is steady. He thinks the discomfort may be worse for a day or two after drinking
 more than usual. He has no other symptoms. There is nothing of relevance in either his
 personal or family history. He has not taken any medication for the discomfort and
 takes no regular medications.
(Pharmacists, see reverse for questions)
1. What investigations (if any) would you order?
                                                                                             d) What advice (if any) would you provide?
                                                                                              i) for drug therapy:
2. Would you prescribe a drug at this presentation?
  □ yes □ no
                                                                                             ii) other (eg lifestyle advice):
  If no, please go to question 3
  If yes,
  a) please specify your choice:
       _____________________________            ______________            ______________
  Drug ______________________________ Strength _______________ Frequency ______________    3. If you chose not to write a prescription,
       _____________________________            ______________            ______________
  Drug ______________________________ Strength _______________ Frequency ______________      a) please explain why not:
  b) When would you expect to see benefit from the drug therapy used (if any)?
                                                                                             b) what advice (if any) would you provide?
  c) When would you review this therapy?
                                                                                             Adapted from a case study developed by the National Preferred Medicines Centre Inc., Wellington, New Zealand.
    Sending in the forms
    Closing date for submission 28 February 2001.
                                                    NPS Level 1/31 Buckingham St
                                                    SURRY HILLS NSW 2010
                                                                                                                                     N P S
    Send the completed case study to:               or fax to:(02) 9699 5155
                                                                                                                         National Prescribing Service Limited

								
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