Friday, April 6, 2012

Choose...But Choose Wisely, Part 3

OK, moving on to the American Gastroenterological Association's list of five things that should be questioned.

1.  For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
This is a good one.  Proton pump inhibitors are Prilosec, Protonix, Nexium and the like.  Pharmaceutical companies have done a great job at turning what used to be called "heartburn" into the much scarier sounding "gastro-esophageal reflux disease."  Suddenly, everyone thinks that they HAVE to be on one of these medications, or else permanent, lasting damage will be done to their esophagus.  Don't believe me?  Before the patent on Prilosec expired, it accounted for 39% of Astra-Zeneca's revenue.  In 2009, PPI revenue for drug companies was $13.1 billion.  Yup, that's billion, with a "b".  Once patients get on these drugs, they seem to stay on them forever.  Now, we a starting to see some problems.  Long-term PPI use is associated with a higher risk of hip fracture.  Many of them interfere with other drugs.  They are also associated with a higher risk of aspiration pneumonia and c. dificile colitis.  A lot of heartburn can be cured with lifestyle changes, such as diet change and weight loss, rather than taking a pill.


2.  Do not repeat colorectal cancer screening (by any method) for 10 years
after a high-quality colonoscopy is negative in average-risk individuals.
Enough said.  Why anyone would want to have a colonoscopy more often than this is beyond me.


3.  Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high- grade dysplasia, completely removed via a high-quality colonoscopy. 
Same as above.  Even with polyps, if it is just one or two small ones, you don't need another colonoscopy before five years have passed.


4.  For a patient who is diagnosed with Barrett’s esophagus, who has
undergone a second endoscopy that confirms the absence of dysplasia
on biopsy, a follow-up surveillance examination should not be
performed in less than three years as per published guidelines.
Barrett's esophagus is a condition where there are pre-cancerous changes in cells lining the esophagus.  This recommends that follow-up in certain cases should be only every three years.


5.  For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
This is another good one. Functional abdominal pain syndrome is similar to irritable bowel syndrome, but the pain is not related to having a bowel movement or to eating.  Patients present with chronic abdominal pain.  It is a diagnosis of exclusion, meaning that other things need to be ruled out via lab tests and imaging.  However, once the diagnosis is made, further testing and imaging should be avoided.  This is important, as patients with functional abdominal pain syndrome often see multiple doctors in an attempt to find some relief.  These otherwise well-meaning doctors often order more imaging, often times because it's hard to throw up your hands and admit that there's nothing else to do.  However, repeated CT scans can increase the risk of cancer due to radiation exposure.


More to come...
  

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