Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12 - 14, 2018 • 222 Dr. Michael Kolber • PEACE RIVER • AB GI FOR THE GP Overview: In this session, we will focus on reviewing clinically relevant and common areas of gastrointestinal medicine seen in primary care. Potential topics reviewed could include (but are not limited to): • Gastroesophageal reflux disease (diagnosis and therapies), • Gastroprotection (who needs it and how to do it) • Proton Pump Inhibitors: benefits and potential adverse events • Barrett's esophagitis (who to screen, how often and how) • Celiac Disease • All plugged up (evidence based approach to constipation) • Irritable bowel syndrome dietary treatments, • C. difficile: risk factors, diagnosis and treatment (including fecal microbiota transplant) • Colorectal Cancer Screening evidence and guidelines • New tests in GI medicine: FIT, fecal calprotectin 1. To review the evidence pertaining to the diagnosis, treatment and prognosis of common gastrointestinal symptoms or conditions seen in primary care 2. To understand the potential benefits and harms of medications commonly used in treating GI conditions 3. To review current colorectal cancer screening guideline 4. Review rural Family Physicians' ability to perform endoscopy
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Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE
ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12 - 14, 2018
• 222
Dr. Michael Kolber • PEACE RIVER • AB
GI FOR THE GP Overview: In this session, we will focus on reviewing clinically relevant and common areas of gastrointestinal medicine seen in primary care. Potential topics reviewed could include (but are not limited to): • Gastroesophageal reflux disease (diagnosis and therapies), • Gastroprotection (who needs it and how to do it) • Proton Pump Inhibitors: benefits and potential adverse events • Barrett's esophagitis (who to screen, how often and how) • Celiac Disease • All plugged up (evidence based approach to constipation) • Irritable bowel syndrome dietary treatments, • C. difficile: risk factors, diagnosis and treatment (including fecal microbiota transplant) • Colorectal Cancer Screening evidence and guidelines • New tests in GI medicine: FIT, fecal calprotectin 1. To review the evidence pertaining to the diagnosis, treatment and prognosis of common gastrointestinal symptoms or conditions seen in primary care 2. To understand the potential benefits and harms of medications commonly used in treating GI conditions 3. To review current colorectal cancer screening guideline 4. Review rural Family Physicians' ability to perform endoscopy
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From Gums to Bums GI Update for Rural Physicians Mike Kolber MD, CCFP, MSc
SRPC April 2018
Faculty/Presenter Disclosure
• Faculty/Presenter: Mike Kolber • Rural FP with special interest in GI: Peace River • PEER Group, University of Alberta Department of Family Medicine
• Where get Personal $: U of Alberta Department of FM • Where get Grant/ Program $: Alberta College of FPs, Toward
OpNmized PracNce • RelaHonships with commercial interests:
– Grants/Research Support or Speakers Bureau: None – ConsulHng Fees: Not applicable – Other: emprss: U of A spin off, quality metrics in medical procedures
• Intellectual COI: Alberta Government Expert Drug CommiWee
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ExperienNal COI
• I enjoy helping paNents feel beWer • I am a drugectomist • My nickname in med school was “Coupons”
On the Menu
• PPIs: “the good, the bad, the labs, the costly” • H. Pylori guidelines: “Evidence, who needs evidence” • What the $%#* is a FODMAP diet… • PancreaNc cancer: moving up the mortality ladder • 4 ways to improve consNpaNon management – Without eaNng “super colon blow cereal”
• Lab tests in GI: Fecal calprotecNn, ATTG, FIT
Proton Pump Inhibitors (PPIs) The Good The Bad The Labs and… The Costly
“Go Ahead… Give me a PPI”
PPIs the Good: They work!
Disease Outcome NNT vs Placebo
UninvesNgated GERD Symptoms 2 Erosive EsophagiNs Healing or symptoms 2
Endoscopic NegaNve Reflux Symptoms 4
1’ prevenNon PUD in NSAID users PepNc ulcers (endoscopic)
4-‐9
Non ulcer dyspepsia Symptoms 10
Rxfiles 2015: accessed Jan 2017 HPE = Helicobactor pylori eradicaNon
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How many Canadians take PPIs? • 2013: 27 million Rxs, 18% adults (CIHI 2016) • All PPIs in top 50 in Canada: Panto #4, Rabrep #26, Eso #27, Lans #29, Omep #50
• 50% may not have appropriate indicaNon – 40% admiWed to medicine – LT care3: 27% demenNa -‐ 18% last week of life! – Asthma, cough, atypical ENT symptoms: does not work4,5
PPIs -‐ The Bad Outcome PaHents / Outcome Study Type Results
Diarrhea All cause RCT 3-‐8%
CDAD Community Cohort 1/10,000 à 2/10,000
CDAD InpaHents + Abx Cohort 8-‐10%
CDAD Recurrent Cohort ~7% ARI (20 !27%) in 3m
CAP (pneumonia) All Cohort 1% ARI per year
CAP (pneumonia) Recurrent Cohort 4% ARI (8-‐12%) in 5 years
OsteoporoNc # Women Cohort NNH 2000 for 1 addiNonal # over 8 years
Plavix plus PPI CVD paNents Cohort ↑ recurrent CVE
Plavix plus PPI CVD paNents RCT No difference CVE
Please see handout for references
PPI associated Adverse Events Possibly Due to residual confounding
J Gen Intern Med 2012; 28(2):223
PPI – The Labs • VB12:1 – Case-‐control: (25K cases, 180k controls)1: • Odds VB12 deficient: ~1.7Xs greater on PPI • >65 yo: 10% (baseline) à 17% on PPI
• Magnesium:2-‐5 – case control, cohort, re-‐challenge – SR: 9 heterogeneous studies; 18-‐27% in ~5 years • Especially if taking diureNcs
Long term PPIs and > 65 yo ! check Vb12 Long term PPIs and on diureHcs ! check Mg
• Depends who takes you golfing! • Individual paNent responses
Khan, Cochrane SystemaFc Reviews 2007, CD003244
PPIs the Costly
• 27 million Canadian Rxs 2013
• Switch à Rabeprazole = save $227 million /year
www.canadianhealthcarenetwork.ca/pharmacists/news/special-‐reports/top-‐100-‐drugs-‐19660/4 Price Comparison of Commonly Prescribed PharmaceuFcals in Alberta 2017
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Alberta Blue Cross 2017 Maximal Allowable Costs
Can paNents stop PPIs? • Yes ~25% successfully stop – Another 30-‐50% decrease dose
• 2 cluster RCTs: academic detailing or paNent informaNon vs standard care 6,7
1Aliment Pharm 2006 ;24: 945 2Am J Gastro 2009; 104:S27, 3Family PracFce, 2014; 31: (6): 625, Quality Primary Care 2012; 20: 141 , J PRIM HEALTH CARE 2016;8(2):164, AP&T 2004; 19: 917; 7Ann Fam Med. 2015;13:545
Study PaHents Recruitment IntervenHon ProporHon successful DC
• Good: PPIs work: 3-‐6-‐9 GERD rule • Bad: PPIs associated with potenNal AEs: – C Diff: Hospital admit, needs Abx à try to stop PPI – C Diff or Pneumonia: stop PPI (↓recurrence)
• Labs: Long term PPIs: check VB12, Magnesium • Costly: use cheapest! • Stopping PPIs: ~25% successful: taper then DC • On demand for NERDS/ most GERD paNents
4 words
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How to choose Hp treatment?
• EffecNveness: – determined by macrolide resistance (< 20% ok) • Avoid macrolide if recent use
– 80% success was ‘benchmark standard’
• Keep it Simple: improves adherence • Cost: double length of therapy = double cost
• 1st line: CLAMET: PPI, CLarithro, Amoxil, METro • 2nd line: QUAD: PPI, bismuth, Tetra, Metro • 3rd line: LEVOQUIN: PPI, amoxil, Levoquin • Removed: triple and sequenNal therapy!
Gastroenterology 2016;151:51
2016 HP Guidelines • 14/15 statements: “strongly recommended” • 14 /15 statements: supported by very low or low quality evidence
Gastroenterology 2016;151:51
“The lack of availability of data on local suscepFbility pa\erns and eradicaFon success rates was a knowledge gap that has a major impact on the choice of therapy and hence best management”
TOP Alberta 2016 HP Guidelines
Teaching Point: If fail HP eradicaNon à use different regimen
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HP in Rural Canada • Peace River: 2011-‐121: 251 gastroscopies – 12.4% HP posiNve, 17.6% if 1st Nme gastro • HP ↑ in UGI bleed, FHx gastric cancer and PUD paNents • HP ↑(but NSS) with age (24% if > 65 yo)
• Moose Factory: 2009-‐112: 304 gastroscopies – 38% pts HP+: gastro with selecNve HP biopsy
• Consider Test and Treat if HP rates> 20%
Can Fam Phys 2016; 62; e547 Can Fam Phys 2013;59:e182
HP 2018 Summary
• In Canada: unNl local resistance known…no need to change HP regimens – Triple Therapy: 10-‐14 days ~80% success (7d = 70%) – SequenNal 10 days: ~90% success – Quadruple Therapy x 14 days = 336 pills!
• If fail one treatment: use a different regimen • Test and Treat for HP for rural dyspepNcs – as HP likely >20%
Kolber personal communicaNon 2016, TOP HP guidelines 2016, Helicobacter 2017, Laine Gastro 2016;151:9
PancreaNc Cancer “We’re #4 -‐ Soon to be #3”
Canadian Cancer Stats 2017
Age Standardized Survival
What the $%&# is a FODMAP DIET (and what’s the evidence for IBS)?
Fermentable oligo-‐, di-‐, monosaccharides, and polyols [FODMAPs]
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FODMAP diet for IBS
• TFP 142: “Low FODMAP diet may improve symptoms for paHents with primarily diarrhea subtype IBS. However, most studies were low quality (small #s, short duraHon)”
• More high quality studies are needed.
TFP #142, 2015, Can Fam Phys 2015, 691
FODMAP Evidence (All from Secondary Care)
• Best RCT1: 6 weeks Danish, open label, 123 IBS pts – IBSS: FODMAP ↓ 150 > probioNcs >> normal diet – Sub-‐group: only worked in diarrhea IBS
• Other RCTs2-‐4: small #s, Nme (2 days), COI ($)
• 2016 RCT IBS-‐D:5 FODMAP vs mNICE diet – frequent small meals, avoid triggers, alcohol, caffeine
– Adequate pain relief: 4 weeks: FODMAP 52 vs 41% (NSS) – ↓abdominal pain: 51 FODMAP vs 23% (NNT =4)
3 FODMAP Meta-‐Analysis = 3 Different Conclusions “More research required to establish LT efficacy1”
“… is efficacious in treaNng funcNonal GI symptoms2” “….FODMAP diet RCTS characterized by high risk of bias…risk that effects reported are driven primarily by a placebo response.”3
– Placebo: 1st BM ~1 day sooner – due to senna – PEG: 1st BM 1-‐2 days sooner with PEG.
TFP #161 April 25, 2016. CADTH 2014 Docusate (Calcium or Sodium) for the PrevenNon or Management of ConsNpaNon
2. Use OsmoHc Agents (PEG)
• TFP 2011: “In adult and pediatric paFents with chronic consFpaFon, PEG more effecFve than other agents. Compared to placebo, it relieves consFpaFon in 1in every 2-‐3 paFents and adds 1-‐3 BMs / week”
• PEG vs lactulose: ↑ stool frequency and ↓ intervenNons (especially in peds)