Alimentary Tract
Gastro-protective strategies in primary care in Italy: The “Gas.Pro.” survey

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Abstract

Introduction

Risk of gastrointestinal injury is relevant among users of anti-inflammatory or cardio-protective drugs. Adequate gastro-protection is warranted in high-risk patients.

Aim

To assess the perceptions and practices of Italian primary care physicians regarding gastro-protective strategies.

Methods

Nationwide cross-sectional observational study. A 14-question survey questionnaire was administered to 112 primary care physicians throughout Italy. Data collection covered consecutive outpatient candidates for the prescription of a potentially GI harmful medication, observed in the physicians’ office over a 3-week period.

Results

Cohort included 3943 cases (2489 naïve and 1463 chronic NSAID/ASA users). Mean age and prevalence of cardiovascular comorbidity were significantly higher in the latter subgroup. Non-selective NSAIDs and low-dose aspirin were the most commonly prescribed drugs. Combined NSAIDS/ASA plus steroids/anticoagulant/antiplatelets were recorded in 161 cases. Helicobacter pylori status was known in only 38% of naïve and 33.2% of chronic users, being negative in 85.3% and 89.5%, respectively. When positive, H. pylori was eradicated by almost all physicians (97.9%), but in case of unknown H. pylori status, the presence of infection was investigated in only 8.6% and 14.9% of patients in the two subgroups. Gastro-protection was endorsed in 80.7% of patients, mostly PPIs (91%). In patients aged over 70, pantoprazole and lansoprazole were the preferred gastro-protective agents.

Conclusions

There is a significant over-use of gastro-protection in the primary care setting in Italy and the role H. pylori is largely overlooked. Educational efforts should be directed to a more targeted gastro-protection only for at-risk patients as well as improved adherence to recommendations for testing and treating H. pylori infection.

Introduction

Pharmacological therapy of patients suffering from common disorders such as cardiovascular, rheumatological or post-traumatic/orthopaedic disease is mainly focused on the treatment of the basic condition, the prevention of acute events or the improvement of symptoms. However, particularly for the gastrointestinal (GI) system, the risk of injury is a relevant factor of morbidity and mortality among users of anti-inflammatory agents (both non-steroidal and steroidal), cardiovascular drugs such as antiplatelet agents or anticoagulants, or selective serotonin reuptake inhibitor (SSRI) antidepressants [1], [2], [3], [4]. In addition, the presence of severe comorbidity (especially cardiovascular disease), personal history of complicated peptic ulcer, advanced age, concomitant use of anticoagulants, corticosteroids, combination of NSAIDs and low-dose aspirin or high-dose NSAID therapy, all characterize a subgroup of patients at highest risk of severe GI complications, ranging from ulcer development to haemorrhage or perforation [3], [4], [5], [6].

In order to prevent or reduce the occurrence of such GI complications, adequate gastro-protective agents (GPA) therapy should definitely be endorsed in these high-risk subjects, as recommended by several guidelines [7], [8], [9], [10], [11]. Unfortunately, potential GI side effects are often overlooked or underestimated by primary care physicians (PCP), with studies revealing low levels of GPA co-prescription for non-selective NSAID users in many primary care settings, even among high-risk patients [12], [13]. Moreover, a number of population-based studies carried out in Europe and the U.S. indicate that GPA therapy is often underutilised also by specialists [14], [15], [16].

A nationwide survey was carried out to assess the perceptions and practices of Italian PCPs regarding the use of potentially GI harmful drugs (aspirin, NSAIDs, COX-2 inhibitors, etc.) and their attitude toward gastro-protection strategies.

Section snippets

Methods

The study was performed under the patronage of the Italian Society for Digestive Endoscopy (SIED). Between October and December 2008, a cross-sectional observational study was carried out in cooperation with a group of primary care physicians in Italy. An independent scientific board composed by three expert members of the Italian Society for Digestive Endoscopy was committed to the realization of protocol design and its case report form as well as the supervision of project status.

According to

Demographic and clinical data

A total of 140 primary care physicians throughout Italy were invited and 112 finally agreed to the project (80%). These were subsequently given a set of questionnaires for patient-data collection and completed the investigation, which produced a population survey of 3943 observed cases, with a mean of 35 filled questionnaires/physician.

Mean age of the cohort was 64 ± 15 years, with significant difference between naïve and chronic NSAID/ASA users (61.9 ± 15.5 vs. 69.5 ± 12.4, p = 0.001). In both

Discussion

The implication of chronic NSAID use in the development of severe and potentially life-threatening GI complications is well established. The risk associated with current use is 3.7 (95% CI 3.1–4.3) for conventional NSAIDs and 2.6 (95% CI 1.9–3.6) for Coxibs [2]. The same is true for the use of low-dose ASA for cardio-prophylaxis, associated with a two- to fourfold increase in upper GI adverse events [17]. Dyspeptic symptoms are estimated to occur in 10–60% of NSAIDs users and lead to

Conflict of interest

None declared.

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  • Cited by (8)

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