Patient choice can help target dyspepsia care

Initiating treatment with an antacid and stepping up appears to achieve results similar to beginning with a PPI and stepping down.

By Victoria Stagg Elliott — Posted Feb. 16, 2009

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Starting patients with dyspepsia on antacids, and, if those don't have the desired effect, moving them on to H2-receptor antagonists and then proton pump inhibitors, is as effective at achieving a resolution of symptoms in six months as taking these steps in reverse order. This research appears in the Jan. 17 Lancet. Beginning the journey on antacids is slightly more cost-effective, although this differential disappears if generic drugs are used.

Physicians noted the findings do not counter the approaches advanced in existing guidelines from the American Gastroenterological Assn. and American College of Gastroenterology that prefer PPIs for acid suppression. An accompanying editorial suggested PPIs are still the appropriate first choice, and physicians say they will continue to favor these drugs when initiating therapy.

"Overall, these are very safe medications," said John Inadomi, MD, chief of clinical gastroenterology at San Francisco General Hospital and professor of medicine at the University of California, San Francisco.

Rather, because these interventions were shown to achieve similar results, patient preferences and other factors such as insurance coverage or side effect concerns should play a bigger role in choosing the first step.

"What this study has told us is that it's very unlikely that we will ever have very restrictive treatment guidelines for dyspepsia," said A. Mark Fendrick, MD, professor of internal medicine as well as health management and policy at the University of Michigan, Ann Arbor. "If you take the outcome at face value, the decision of whether you're going to step up or step down can be put more in the hands of the patient in consultation with the physician."

Experts praised this project for attempting to study dyspepsia treatment in a real-world, primary care setting.

Researchers in the Netherlands randomized 664 patients presenting with this problem to a family physician to either a "step up" or "step down" treatment strategy. If after four weeks the particular drug did not have the desired effect, the patient moved on to the next step. After six months, 72% of patients in the group starting with antacids achieved remission. Seventy percent of those who began with a PPI did as well. The rate of adverse events was comparable.

"It's very interesting, and it's very provocative," said Joel Heidelbaugh, MD, clinical assistant professor of family medicine at the University of Michigan, Ann Arbor.

But others offered specific criticisms of the study and its findings. For instance, it's unclear which strategy resolved symptoms faster. The cost-effectiveness may not be generalizeable to the American medical system. Also, patients with gastroesophageal reflux disease and dyspepsia were lumped together in the study population. "They unfortunately used these terms interchangeably, but they're not," said Dr. Heidelbaugh. PPIs play a role in both, although physicians say these patients can require different treatment management.

In addition, subjects were told not to come back if symptoms had resolved, and experts suspect some appointments may have been canceled for other reasons.

"There are a lot of reasons why a patient would cancel an appointment. They don't have a car. They have to work," said, John Allen, MD, medical director for quality for Minnesota Gastroenterology in St. Paul and chair of the AGA's clinical practice committee. "I don't think this study answers the key question they're asking."

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Study at a glance

What is the most cost-effective way to treat dyspepsia?

Objective: Determine the best empirical treatment strategy for new onset dyspepsia with regard to money spent and resolution of symptoms.

Methods: Researchers in the Netherlands randomized 664 patients with dyspepsia presenting in the primary care setting to initiate treatment with antacids and move up to stronger medications as necessary, or to start with a proton pump inhibitor and move down if those drugs were not effective.

Results: After six months, 72% of those in the step-up group and 70% in the step-down group had relief of symptoms. The average medical cost for those who started with the antacid was $292.49. Those on the PPI at first spent an average of $314.34, although these cost differences disappeared when generic medications were used.

Conclusions: Both strategies can treat dyspepsia successfully. The step-up strategy is more cost effective when using branded medications. When using generics, expenses are similar.

Source: "Effect and cost-effectiveness of step-up versus step-down treatment with antacids, H2-receptor antagonists, and proton pump inhibitors in patients with new onset dyspepsia (DIAMOND study): a primary-care-based randomized controlled trial," abstract, The Lancet, Jan. 17 (link)

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External links

"Dyspepsia and reflux in primary care: rough DIAMOND of a trial," extract, The Lancet, Jan. 17 (link)

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