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 20 May 2018

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News

Step-up vs step-down therapy with H2-receptor antagonists and PPIs in dyspepsia

This week’s The Lancet examines the effect and cost-effectiveness of step-up vs step-down treatment with antacids, H2-receptor antagonists, and PPIs with new onset dyspepsia.

News image

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Substantial physician workload and high costs are associated with the treatment of dyspepsia in primary health care.

Despite the availability of consensus statements and guidelines, the most cost-effective empirical strategy for initial management of the condition remains to be determined.

Dr Corine van Marrewijk and colleagues from the Netherlands compared step-up and step-down treatment strategies for initial management of patients with new onset dyspepsia in primary care.

Patients aged 18 years and older who consulted with their family doctor for new onset dyspepsia in the Netherlands were eligible for enrolment in this double-blind, randomized controlled trial.

1 or more adverse drug events were reported by 28% in the step-up group
The Lancet

Between 2003 and 2006, 664 patients were randomly assigned to receive stepwise treatment with antacid, H2-receptor antagonist, and proton pump inhibitors, or these drugs in the reverse order.

The patients were randomized by use of a computer-generated sequence with blocks of 6.

The team found each step lasted 4 weeks, and treatment only continued with the next step if symptoms persisted or relapsed within 4 weeks.

Primary outcomes were symptom relief and cost-effectiveness of initial management at 6 months.

Analysis was by intention to treat; the intention to treat population consisted of all patients with data for the primary outcome at 6 months.

The researchers found that 332 patients in the step-up, and 313 in the step-down group reached an endpoint with sufficient data for evaluation.

The main reason for dropout was loss to follow-up.

Treatment success after 6 months was achieved in 72% of patients in the step-up group and 70% of patients in the step-down group.

The team found that the average medical costs were lower for patients in the step-up group than for those in the step-down group, which was mainly because of costs of medication.

The research team noted that 1 or more adverse drug events were reported by 28% of patients in the step-up, and 29% of patients in the step-down group.

All were minor events, including dyspeptic symptoms, diarrhea, constipation, and bad/dry taste.

Dr van Marrewijk and colleagues concluded, “Although treatment success with either step-up or step-down treatment is similar.”

“The step-up strategy is more cost effective at 6 months for initial treatment of patients with new onset dyspeptic symptoms in primary care.”

Lancet 2009: 373(9659): 215-25


21 January 2009

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