VINCENZO  SAVARINO

Direttore Clinica GastroenterologiaUniversità degli Studi di Genova

DISPEPSIA : ORIENTAMENTO TERAPEUTICO.

VINCENZO SAVARINO

UNIVERSITÀ DI GENOVA

Patients with dyspepsia may haveunderlying structural disease

Cancer 2%

Normal 54.4%

Reflux esophagitis23.9%Peptic ulcer

disease 19.9%

Richter, 1991

FUNCTIONAL DYSPEPSIA - PATHOPHYSIOLOGYAbnormality Prevalence Symptoms Therapy

Gastroparesis 25 - 40% Postprandial Prokineticfullness, nausea,vomiting in females

Impairedaccomodation 40% Early satiety ?

Visceralhypersensitivity 60% Fullness, pain in ?

fasting state Gastric acid hypersecretion 5 - 10% Pyrosis, pain Antisecretory

drugsH. pylori 20 - 40% ? Eradication

Abnormal centralperception ? ? ?

Treatment options in functional dyspepsiaTreatment options in functional dyspepsiaTreatment options in functional dyspepsia

FunctionalDyspepsia

Muco-protectiveagents

Acid inhibition

Prokinetic motilityagents

H. pylori eradication

PhytotherapeuticsCarminatives

Anti-depressantsAnti-serotoninergics

Opioids

Functional dyspepsia

Talley et al., Aliment Pharmacol Ther 1999; 13: 1135–48.Talley et al., Gut 1999; 45(Suppl II): II37–42.

Meta-analysis – 22 studies of H2RAs vs placebo 1985–199715 of 22 had a positive result for H2RAs

Redstone et al., Aliment Pharmacol Ther 2001; 15: 1291–9.

(1.2–2.8)*1.8Complete relief of epigastric pain

(1.6–3.3)*2.3Improvement of epigastric pain

(0.9–2.3)1.48Global assessment of dyspepsia symptoms

95% CIOdds ratio for H2RA

*statistically significant result

H2RAs in the treatment of functional dyspepsia

HH22RAs in the treatment of RAs in the treatment of functional dyspepsiafunctional dyspepsia

Talley et al., Aliment Pharmacol Ther 1998; 12: 1055–65.

Superior to placebo, but not in dysmotility-like dyspepsia

Bond and Opera studies (n=1248, intention to treat)

Treatment Complete symptom relief (%)

Functional dyspepsia: PPI therapyFunctional dyspepsia: PPI therapy

Omeprazole 20 mg 38*

Omeprazole 10 mg 36*

Placebo 28

P<0.02-0.002

Peura et al., Gastroenterology 2000; 118(Suppl 2): A439.

0

10

20

30

40

50

60

Week 4(n=775)

Week 8(n=802)

Patie

nts

repo

rtin

gco

mpl

ete

sym

ptom

relie

f (%

)

**

* *

*p≤0.05 vs placebo

GORD and IBS patients excluded

Placebo

Lansoprazole 15 mg/day

Lansoprazole 30 mg/day

Intention-to-treat analysis

Lansoprazole in functional dyspepsia: symptom resolution

LansoprazoleLansoprazole in functional dyspepsia: in functional dyspepsia: symptom resolutionsymptom resolution

Forest plot of randomized controlled trials comparing PPItherapy with placebo in uninvestigated dyspepsia

Talley et al, Gastroenterology 2005

Forest plot of randomized controlled trials comparingPPI with H2RA therapy in uninvestigated dyspepsia

Talley et al, Gastroenterology 2005

Forest plot of randomized controlled trials of PPI therapyversus placebo in patients with nonulcer dyspepsia

Talley et al, Gastroenterology 2005

Individual and summary relative risks and 95% CIs from 7 studiescomparing PPIs with placebo for the treatment of functional dyspepsia.

Wang et al, Clin Gastroenterol Hepatol 2007

0

20

40

60

Predominant pain

(n=708)

Predominantheartburn(n=143)

Predominantdiscomfort(n=291)

OME 20 mg od

OME 10 mg od

Placebop=0.002

p=0.02

p=0.002

p=0.02

ns

Omeprazole efficacy in ulcer-likeand reflux-like functional dyspepsia

TALLEY ET AL., APT 1998

Sym

ptom

free

patie

nts(

%)

Farup et al., 1999

Variables affecting the response or not to PPI therapy in patients with functional dyspepsia

Statistical Results Comparing PPIs With Placebo in Subgroups of Functional Dyspepsia Under

Random-Effects Model

Wang et al, Clin Gastroenterol Hepatol 2007

Drug Trials No. patients Relative riskreduction (95% CL)

Prokinetic 12 829 50% (30 to 65)

Antisecretory drugs 12 2373 21% (-1 to 48)

Antacids 1 109 -2% (-36 to 24)

Bismuth 6 311 40% (-3 to 65)

Sucralfate 2 246 28% (-40 to 64)

Meta-analysis of 33 controlled trials on pharmacological therapies of NUD

MODIFIED FROM SOO ET AL., DDW 2000

0

10

20

30

40

50

60

70

80

Placebo

Res

pons

e (%

)

13

73

Veldhuyzen van Zanten et al., Am J Gastroenterol 1996; 91: 660–73.

Functional dyspepsia: placebo effect (meta-analysis)

Functional dyspepsia: placebo effect (meta-analysis)

The Maastricht European Consensus Guidelines on the management of dyspeptic patients in primary care

< 45 years* withoutalarm symptoms

> 45 years or withalarm symptoms (irrespective of age)

Review patient’s historyTest for H.pylori• 13C-UBT or• Laboratory serology

Refer togastroenterologist

If H. pylori-positive,treat the infection

*The cut-off age may be below 45 years, depending on regional differences in the incidence of gastric malignancy

The European H.pyloriStudy group 1997

Dyspeptic patients1st primary care visit

Forest plot of randomized trial of H pylori eradication versus endoscopy in patientswith dyspepsia. Proportion of patients with cure of dyspepsia at 1 year.

Talley et al, Gastroenterology 2005

Talley et al, Gastroenterology 2005

Forest plot of randomized trial of H pylori eradicationversus endoscopy in patients with dyspepsia. Proportion of

patients who underwent endoscopy.

STUDY Success in FD patients (vs controls) Risk ratio (95% CI)Talley et al 32/135 vs 31/143 1.1 (0.6–2.0)Blum et al 45/164 vs 34/164 1.4 (0.8–2.5)Talley et al 69/162 vs 71/155 0.9 (0.5–1.4)McColl et al 33/160 vs 11/158 3.5 (1.6–7.6)David et al 14/17 vs 15/24 2.8 (0.5–16.5)Koelz et al 55/89 vs 61/92 0.8 (0.4–1.6)Passos et al 40/45 vs 32/36 1.0 (0.2–4.8)TOTAL 288/772 vs 255/772 1.29 (0.89–1.89)

LAINE ET AL., ANN INTERN MED 2001

0.1 1 10 100

Favour no H. pylori therapy Favour H. pylori therapy

Meta-analysis of 7 trials on H. pylorieradication in non-ulcer dyspesia

Talley et al, Gastroenterology 2005

Forest plot of randomized controlled trials of H pylorieradication therapy versus placebo antibiotics in H pylori–positive patients with nonulcer dyspepsia.

Placebo response in functional dyspepsia

2-5 patients need treatment with prokinetics to improve 1 case

6-11 patients need treatment with antisecretory drugs to improve 1 case

15 patients need treatment with H. pylori eradication toimprove 1 case

No. of patients needed to be treated to have success

30 - 60 %

Linee guida nella gestione del paziente con dispepsia funzionale

• Per i pazienti con meno di 55 anni di età e senza aspetti di allarme

• Ricerca dell’H. pylori con test del respiro o dosaggio antigene fecale e suo trattamento

• Gli IPP sono usati con gli antibiotici per eradicare la suddetta infezione o da soli per sopprimere la secrezione acida con modesti risultati

• Se il paziente rimane sintomatico nonostante l’eradicazione dell’H. pylori o non risulta infetto, 4 settimane di terapia empirica con IPP è la strategia di scelta.

• L’endoscopia non è necessaria persino nei pazienti che non rispondono alle suddette misure terapeutiche

• Tuttavia, il medico deve sempre valutare la necessitàdella sua esecuzione nell’ambito del singolo contesto clinico.

Linee guida nella gestione del paziente con dispepsia funzionale

• Per i pazienti con più di 55 anni e/o con aspetti di allarme

• L’esecuzione di un esame endoscopico del tratto digestivo superiore con biopsia per la diagnosi di H. pylori è l’approccio iniziale preferibile.

• Il trattamento deve essere effettuato in relazione alla diagnosi di malattia organica o funzionale.

Conclusioni

• Nessuna delle attuali terapie risulta essere altamente efficace nella dispepsia funzionale

• Tuttavia, gli inibitori di pompa protonica sono piùefficaci del placebo in un sottogruppo di pazienti che soffrono principalmente di dolore epigastrico

• Anche l’eradicazione dell’infezione da H. pylori èefficace in un ridotto numero di questi pazienti

Mangiare è umano

Digerire è divino

Mark Twain