Experts Criticise NICE Over 'One Size Fits All' Approach To Treating Dyspepsia

Today (Wednesday 25th August 2004 ) the National Institute for Clinical Excellence (NICE) has published the guideline: 'Dyspepsia: managing adult patients in primary care'.1 The publication puts the responsibility for managing a diverse range of dyspeptic patients firmly within primary care. However REFORM (REflux FORuM), a multidisciplinary group of primary care professionals, are concerned that some aspects of the guideline represent a confusing departure from current best practice and that this may lead to serious conditions being missed and resources wasted.

The main principle of the guideline is to relieve pressure on overworked secondary care endoscopy services, by advocating an empirical step-down approach to treating 'uninvestigated dyspepsia' for patients presenting with 'dyspeptic' related symptoms in primary care.

Dr Ian Allwood, Chair of REFORM, commented: "Primary care is very well-placed to manage patients with all types of dyspeptic disorders; it is logical for the GP to take the lead role in both the diagnosis and the ongoing management of these patients. Our chief concern, though, is that dyspepsia is only an umbrella term for symptoms which may be caused by a range of quite diverse conditions - unless we make some attempt to differentiate conditions like Gastro-oesophageal reflux disease (GORD) from those which have other pathological roots, then we cannot be fully confident of offering the right kind of care at the point of consultation or further down the line. I fear that effective management of our patients' conditions, as well as healthcare resources, could be significantly compromised if the NICE guideline is adhered to injudiciously."

To further reduce the pressure on endoscopy services, investigation by endoscopy is being discouraged in all patients without alarm symptoms - a major change from the original NICE guidance published in 2000 which recommended referral for all patients with dyspepsia over the age of 552. REFORM recognise the rationale for such restrictions but stress the need to ensure all members of the primary care team are aware of the dangers of untreated GORD, a condition which is linked with a 10-15%3 increased risk of developing Barrett's oesophagus - in turn associated with a 40-fold increased risk of developing oesophageal adenocarcinoma3. It is of serious concern that the incidence of oesophageal adenocarcinoma has risen faster than any other cancer in the last 30 years3.. This is particularly alarming, considering that 1 in 4 of the UK population are affected by GORD4.

Dr Allwood continues: "We agree that endoscopies are sometimes unnecessary and inconclusive - but the appearance of heartburn has consistently been shown to strongly correlate with an accurate diagnosis of GORD and so represents a reasonable alternative. This is already best practice in primary care - it seems logical that functional guidelines from NICE would take this into account instead of trying to make one basic approach fit every condition".

Nevertheless, REFORM are supportive of some specific treatment recommendations made by NICE in relation to tackling GORD as quickly and effectively as possible. Dr Allwood explains: "Our first priority for patients with GORD must be to control their symptoms and heal any oesophageal damage quickly. Stepping up through incremental doses and treatments not only increases the risk of disease progression, but unnecessarily extends the considerable impact this condition can inflict on a patient's quality of life. It is at least reassuring that, in the absence of guidance on differentiating conditions like GORD from other dyspeptic conditions, NICE is making some attempt to safeguard the vulnerable patient".

The aim of REFORM is to provide tools and information to support the marrying of national guidance with grassroots primary care practice and experience. REFORM has produced a guide to support GPs in the management of GORD. This guidance and additional resources to help GPs manage reflux disease can be found at www.refluxforum.co.uk

About REFORM

            *          The REflux FORuM (REFORM) is a multidisciplinary group comprising GPs, pharmacists and pharmaceutical advisers with expert advice from gastroenterologists, nurses and surgeons.

            *          REFORM is committed to raising standards and providing the primary care team with practical solutions for the diagnosis and management of patients with reflux disease.

            *          The REFORM group are sponsored by an unrestricted educational grant from AstraZeneca.

References

1.         National Institute for Clinical Excellence. Dyspepsia: managing adult patients in primary care. August 2004

2.         National Institute for Clinical Excellence. Guidance on the use of proton pump inhibitors in the treatment of dyspepsia. 2000

3.         Fennerty B. Update on Barrett's oesophagus. Presentation at the Digestive Disorders Week, Atlanta , Georgia , USA , May 2001

4.         Jones, R. Gastro-oesophageal reflux disease in general practice. Scand J Gastronenterol 1995; 30 Suppl 211:35-38