KISS of the NICE 2014 Dyspepsia and GORD guideline

NICE 2014 Guideline

NICE are updating their cancer referral guidelines (due May 2015) which will provide further guidance on referral pathways. In the meantime, any clinical suspicion of cancer ‘red flags’ obviously warrants urgent referral. There are some significant changes, including a more active approach to test and treat for HP, lowering threshold for endoscopy in GORD, cutting back on long-term full dose PPIs and lowering the threshold for consideration of surgical referral in persistent GORD.

Common elements of care

·      Diagnosis

o   Consider cardiac or biliary disease in the differential diagnosis

o   If people have had a previous OGD and have no new alarm signs, manage according to previous endoscopic findings

·      Appropriate lifestyle advice, including avoidance of known precipitants

o   Smoking, alcohol, caffeine, chocolate, fatty foods and being overweight

·      Review medications for possible causes, including

o   CCBs, nitrates, bisphosphonates, NSAIDs (including OTC) and steroids

·      Encourage people using medication long-term to reduce stepwise

o   Lowest dose, intermittent use and returning to self treatment with antacid therapy as needed

Who should we refer?

·      If present with dyspepsia and significant GI bleeding, refer immediately (as if we wouldn’t!)

·      Consider endoscopy if the person has GORD (to diagnose Barrett’s) based on patient preference and risk factors (e.g. long duration of symptoms, increased frequency of symptoms, previous oesophogitis ort hiatus hernia, male gender)

·      At any age with symptoms which are non-explained or unresponsive to treatment

·      With suspected GORD and considering surgery

·      With HP that has not responded to second-line therapy

How should we manage uninvestigated & functional dyspepsia?

·      Offer empirical full-dose PPI for 4 weeks

·      Offer HP ‘test and treat’

o   HP Testing

§  Leave a 2 week washout after PPI therapy

§  Use a breath or stool antigen test

§  Consider re-testing with a breath test if symptoms persist and offering second-line eradication (see below on eradication)

·      If symptoms recurrent, use lowest possible doses on as needed basis to control symptoms

·      Offer an annual review and encourage them to step-down meds or return to self-treatment with antacids

How should we manage reflux symptoms?

·      Manage uninvestigated reflux symptoms as for uninvestigated dyspepsia

·      If GORD is confirmed on OGD, offer a full dose PPI (Omeprazole 40mg or equivalent) for 8 weeks to heal severe oesophogitis

o   If initial treatment fails, consider a high ‘double’ dose PPI (Omeprazole 40mg bd or equivalent), or switch to another full dose PPI

·      Offer a full dose PPI for maintenance long-term if severe oesophogitis

How should we eradicate HP?

·      Offer a 7 day twice daily course of

o   PPI + amoxicillin + clarithromycin or metronidazole

o   If penicillin allergic: PPI + clarithromycin + metronidazole

§  If pen allergic people have had previous exposure to clarithromycin, offer PPI + bismuth + metronidazole + tetracycline

o   If symptoms persist after first-line therapy, offer a second course of therapy with different components (see full guideline)

o   Refer if symptoms persist after second-line eradication

For further information, please see the full guideline at NICE 2014 Guideline