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Hot Topics Blog

Do PPIs cause stomach cancer?

Simon Curtis - 13 Dec, 2017

Like you, I have seen quite a few patients worried about a reported link between PPIs and cancer over the last couple of months. PPIs have been in the news again recently, with new links to stomach cancer. Some papers reported they ‘raise the chance of stomach cancer by eight times’. That’s a pretty alarming headline to read if you are taking one and very likely to lead to you chucking it in the bin! 

But what did the research actually show? The paper, published in Gut, was a long-term cohort study from Hong Kong, following patients after treatment for helicobacter. The study did indeed show a link between long-term PPIs and stomach cancer, but the media reporting scored a hat-trick of the classic errors of evidence misinterpretation: not accounting for confounding factors, confusing relative and absolute risks and mixing up association with causality. 

In terms of confounding, we know that Chinese people have a higher baseline risk of stomach cancer than other populations and that helicobacter infection also increases stomach cancer risk. So, we have significant confounding factors before we even start to compare to a European population without helicobacter. Furthermore, they were unable to adequately control for other confounding factors such as smoking and alcohol. 

In terms of risk, yes there was a statistically significant increase in relative risk (HR 2.44) of developing stomach cancer compared to controls but in absolute terms there were only 4 additional cases of cancer per 10,000 people per year. The result may be statistically significant, but we have to ask is it clinically significant? Saying that PPIs double cancer risk is understandably alarming for patients, but saying there is an association with one extra case per 2,500 patients with long-term use much less so. 

In terms of association and causality, there are plausible biological reasons why PPIs may increase stomach cancer risk and this is far from the first study to suggest this. Prolonged achlorhydria can cause atrophic gastritis and intestinal metaplasia, and prolonged PPI use has been found in recent research to be associated with polyps in the gastric fundus. Furthermore the Gut paper showed a dose and time effect, the more PPI exposure the greater the risk. That said, like all observational studies, associations do not prove causality and the confounding factors in this research could explain the link. 

Like all drugs, PPIs do have side effects and we are increasingly aware (DTB Oct 2017) that long-term use is associated with a number of adverse events e.g. clostridium difficile infection, fractures, electrolyte disturbances, kidney injury and pneumonia. Many of these associations may be because PPIs are more likely to be taken by older, frailer people with multimorbidity. Nonetheless, the mantra should always be the lowest dose for the shortest possible time

As well as symptom control we know that there are indications when the benefits of PPIs are likely to significantly outweigh the risks with long-term use e.g. Barrett’s oesophagus, previous bleeding ulcers and gastroprotection for NSAIDs. For example, research this year Lancet 2017 has shown the risk of bleeding in older people on low dose aspirin is much greater than previously thought, a risk which can be significantly reduced by PPI cover. These recent papers are a useful reminder that we should always try to avoid unnecessary long-term PPI use, but for our patients who really need them we think this new research is not a cause for alarm

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​NICE guideline on diagnosis and management of asthma November 2017

Rob Walker - 7 Dec, 2017

NICE guideline on diagnosis and management of asthma November 2017

Well, it is finally here months after it’s planned publication - the much anticipated NICE guideline on asthma. NICE has now collected a hat trick of prize guidelines in the last year or so, for a variety of reasons - multimorbidity (most influential for attitude changing), back pain (most honest) and now asthma (most controversial).

Asthma remains a difficult condition to manage in primary care and as GPs I’m sure we feel stuck in the middle a lot of the time - on the one hand we’re accused of over-diagnosing asthma and putting people on unnecessary treatment, and on the other hand under-diagnosing leading to poor outcomes and unwanted hospital admissions. The fact that the NICE guideline has been so delayed in it’s publication and has significant differences to the BTS/SIGN guideline rather underlines that there is still inherent uncertainty as to how to manage this condition and that we are still struggling to get a consensus on the subject. 

NICE have made a laudable attempt in this guideline to help improve the diagnostic accuracy of asthma and get the right people on treatment. However, in an increasing trend which seems to focus on service redesign rather than guide on currently available services, it will leave many areas of the country in a difficult position - raised expectations in the consulting room, and CCGs unable to deliver the service changes due to increasingly stringent budgets.

So what are the key changes? One of main points of the guideline is a focus on objective testing for asthma diagnosis. 'Do not use symptoms alone without an objective test to diagnose asthma’ the guideline states right at the beginning (in contrast to SIGN/BTS where high probability of asthma needs no further testing). The guideline also recommends that for adults TWO objectives tests should be used, with the headline controversial recommendation that fractional exhaled nitric oxide (FeNO) should be tested TOGETHER with spirometry first line (SIGN/BTS recommend spirometry and only further testing if spirometry normal). NICE also recommend commissioners set up diagnostic hubs to 'improve the practicality of implementing the recommendations in this guideline’. 

What about treatment? The main change revolves around step up treatment if symptoms are not controlled on low dose ICS - NICE recommend a 4-8 week trial of leukotrine receptor antagonist (LTRA) before considering LABA (SIGN/BTS suggest the other way around). NICE also recommend using a MART regime (maintenance and reliever therapy) if symptoms are not controlled on fixed low dose ICS/LABA - this involves using a combined low dose ICS/LABA inhaler as both maintenance AND reliever (note this regime can only be used with combination inhlalers using fast acting LABA e.g. formoterol and CAN’T be used with salmeterol inhalers e.g. Seretide). Finally NICE recommend if patients are on ICS monotherapy and get a worsening of asthma control to consider a 7 day quadrupling of ICS therapy (as long as this doesn’t exceed the max daily licensed dose).

So where does this leave us at the moment? If you’re in an area of there country that already has FeNO diagnostics available in primary care, you may wonder what all the fuss is about, but for those that don’t we’re back to making those difficult judgments as to how far to test in primary care with currently available services and when to refer to secondary care. ‘Medicine is a science of uncertainty and an art of probability’ said William Osler, and I think that neatly sums up this area. Thankfully as GPs we are the specialists in managing uncertainties and expectations and will continue to do the best we can for our patients in the context of our local service provision. 

Rob Walker

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Would you like to reduce your workload and improve the management of your chronic disease patients in one go?

Zoe Norris - 19 Dec, 2017

We like to do our bit to try and reduce the stress of the GPs who come on our courses. Sometimes that’s with our handbook, or our KISS guides; this time we want to reduce your stress by talking about your nurses. 

We have always had ANPs come on our main Hot Topics course, with good feedback, but we didn’t offer anything for those practice nurses who weren’t in that group. 18 months ago, in response to requests from our delegates, our wonderful Hot Topics GP Dr Siobhan Becker, and our fabulous ANP Lucy Hamilton teamed up to write a course specifically for them. It is for any nurse who works in primary care and covers a mix of key updates on chronic disease management, minor illness, vaccinations, wound care, and much more. 

The thing is, some nurses find it hard to get the time or funding to come along. This type of course is new to them and to GPs who may not come on our courses themselves, they may not know what to expect. What you can expect by sending your nurses on this course, is for them to be up-to-date with all the latest guidance for their roles. You can expect them to feel more confident in the areas they currently work, and to feel they know enough to explore taking on other skills or disease management. They will know how to work efficiently, effectively and support you by dealing with conditions that may not need to see a GP. 

The Hot Topics team are all practising NHS GPs and nurses; we know what it’s like to be working in practice right now, and we need all our team to be working together to try and free up more time. Having your nurses upskilled, updated, and enthused can only be a good thing for your practice. They will have the same access to the online NB resources, the nurse book, webcast, and the NB App, so their learning for appraisal and revalidation can continue through the year. 

If you’ve left it a bit late to treat your nurses for Christmas, then instead of that bottle of wine or box of chocolates, consider giving them a place on the NB Medical Hot Topics Primary Care Nurse Course. Good for them, good for you. 

Zoe Norris 

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