The Family Practitioner’s Approach to Heartburn, continued. upper GI symptoms using PPIs was related to their relatively high cost and the large proportion of the health budget they took up. With the availability of cheap generics this is no longer an issue. The role of surgery, essentially fundoplication, is not as prevalent in the UK as in many other European countries and the USA and is normally initiated by a gastroenterologist with a referral to a surgeon, rather than directly from a PCP. However, whilst the cost and use of PPIs in the initial management of heartburn is not a major issue for PCPs, there are concerns about their long-term use because of possible significantly detrimental side effects. A substantial proportion of the population is taking PPIs, ranging between 2-15% of the Western population depending on definitions of long-term 7 and the numbers are increasing. In many parts of the world, PPIs are available without a prescription and the rates of usage are even higher. It is hard to determine if there is a strong element of over-prescribing by PCPs because of the widened indications for them – essentially concurrently for gastroprotection with NSAIDs and aspirin. With an increasing elderly population taking such drugs, there has been a steep rise in the use of long-term PPIs. In the UK, PCPs are required to audit their long-term prescribing and to monitor patients for appropriate clinical indications. At the same time, it would appear that patients with GORD are relatively adherent to their medication, even if symptom control is variable, and that severe symptoms and Barrett’s esophagus are associated with increased adherence 8. However, few data are available on the rate of success of strategies to reduce or stop treatment for heartburn or GORD specifically. In summary, a number of problems and questions remain in relation to the PCPs’ responses to heartburn and its management. These include whether the interpretation of the presenting problem was accurate; if the presenting symptom was the issue that needed chief attention or if there were other factors that were key. Additionally, is the level of control of symptoms considered satisfactory and what might be gained from a secondary care opinion? Heartburn remains, essentially, a primary care problem and its interpretation and context within a mix of other symptoms creates a complex issue. What has changed is that it is much less likely to be investigated than in previous years and there is less optimism about the power of PPIs to solve the problem. Nonetheless, the size of the problem is growing and vigilance is needed in at risk groups. References 1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006;101:1900-20. 2. Raghunath AS, Hungin AP, Mason J, Jackson W. Symptoms in patients on long-term proton pump inhibitors: prevalence and predictors. Aliment Pharmacol Ther 2009;29:431-9. 3. Mainie I, Tutuian R, Shay S, Vela M, Zhang X, Sifrim D, Castell DO. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut 2006;55:1398-402. 4. Dent J, Vakil N, Jones R, Bytzer P, Schöning U, Halling K, Junghard O, Lind T. Accuracy of the diagnosis of GORD by questionnaire, physicians and a trial of proton pump inhibitor treatment: the Diamond Study. Gut 2010;59:714-21. 5. Heading R, Thomas E, Sandy P, Smith G, Fass R, Hungin P. Discrepancies between upper GI symptoms described by those who have them and their identification by conventional medical terminology: a survey in four countries. Abstract OP398, UEGW 2015, Vienna. 6. Ness-Jensen E, Lindam A, Lagergren J, Hveem K. Changes in prevalence, incidence and spontaneous loss of gastro-oesophageal reflux symptoms: a prospective population-based cohort study, the HUNT study. Gut 2012;61:1390-7. 7. Haastrup P, Paulsen MS, Begtrup LM, Hansen JM, Jarbøl DE. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract 2014;31:625-30. 8. Hungin AP, Hill C, Molloy-Bland M, Raghunath A. Systematic review: Patterns of proton pump inhibitor use and adherence in gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2012;10:109-16. World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 18
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