Initial management strategies for dyspepsia

Delaney, Brendan; Ford, Alexander C; Forman, David; Martin, Paul; Qume, Michelle

doi:10.1002/14651858.cd001961.pub2

Cited by 66 publications

(37 citation statements)

References 59 publications

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“…This approach is clinically useful given that in previous individual patient data meta-analyses there was only a small, although statistically significant, difference in the relative risk of remaining symptomatic, which favoured prompt endoscopy over “test and treat.”19 Additionally, no difference was found between “test and treat” and empirical acid suppression 22. Furthermore, more randomised controlled trials have been included in our analysis than in the aforementioned individual patient data meta-analyses,1922 and a previous trial based meta-analysis 55. Our meta-analysis was also able to make indirect and direct comparisons by using trial data, which led to a change in the strategy that could be the most effective for first line management of uninvestigated dyspepsia.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

Eusebi

Black

Howden

et al. 2019

BMJ

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ObjectiveTo determine the effectiveness of management strategies for uninvestigated dyspepsia.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, Embase Classic, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov from inception to September 2019, with no language restrictions. Conference proceedings between 2001 and 2019.Eligibility criteria for selecting studiesRandomised controlled trials that assessed the effectiveness of management strategies for uninvestigated dyspepsia in adult participants (age ≥18 years). Strategies of interest were prompt endoscopy; test for Helicobacter pylori and perform endoscopy in participants who test positive; test for H pylori and eradication treatment in those who test positive (“test and treat”); empirical acid suppression; or symptom based management. Trials reported dichotomous assessment of symptom status at final follow-up (≥12 months).ResultsThe review identified 15 eligible randomised controlled trials that comprised 6162 adult participants. Data were pooled using a random effects model. Strategies were ranked according to P score, which is the mean extent of certainty that one management strategy is better than another, averaged over all competing strategies. “Test and treat” ranked first (relative risk of remaining symptomatic 0.89, 95% confidence interval 0.78 to 1.02, P score 0.79) and prompt endoscopy ranked second, but performed similarly (0.90, 0.80 to 1.02, P score 0.71). However, no strategy was significantly less effective than “test and treat.” Participants assigned to “test and treat” were significantly less likely to receive endoscopy (relative risk v prompt endoscopy 0.23, 95% confidence interval 0.17 to 0.31, P score 0.98) than all other strategies, except symptom based management (relative risk v symptom based management 0.60, 0.30 to 1.18). Dissatisfaction with management was significantly lower with prompt endoscopy (P score 0.95) than with “test and treat” (relative risk v “test and treat” 0.67, 0.46 to 0.98), and empirical acid suppression (relative risk v empirical acid suppression 0.58, 0.37 to 0.91). Upper gastrointestinal cancer rates were low in all trials. Results remained stable in sensitivity analyses, with minimal inconsistencies between direct and indirect results. Risk of bias of individual trials was high; blinding was not possible because of the pragmatic trial design.Conclusions“Test and treat” was ranked first, although it performed similarly to prompt endoscopy and was not superior to any of the other strategies. “Test and treat” led to fewer endoscopies than all other approaches, except symptom based management. However, participants showed a preference for prompt endoscopy as a management strategy for their symptoms.Systematic review registrationPROSPERO registration number CRD42019132528.

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Section: Discussionmentioning

confidence: 99%

Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

Eusebi

Black

Howden

et al. 2019

BMJ

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“…Delaney et al . [66] also found the test and treat strategy to be more effective than acid suppression alone and reported a mean additional cost of US$401 for endoscopy. Ebell et al .…”

Section: Economics Of H Pylori Infectionmentioning

confidence: 99%

Helicobacter pylori infection in developing countries: The burden for how long?

Salih

2009

Saudi J Gastroenterol

202

135

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Approximately 50% (over 3 billion) of the world populations are known to be infected with Helicobacter pylori, mainly in the developing countries. Among those, hundreds of millions of people develop peptic ulceration during their lifetime and still tens of millions might progress to gastric cancer. Possible modes of H. pylori transmission generally described are through direct contact between family members and also through contaminated water and food. Because the high prevalence of infection occurs mainly in developing countries and because the test-and-treat strategy puts a huge economic burden on many of these countries, it is time to take an immediate action toward this bacterial infection and adopt a strategy to prevent it. To address this issue, an updated prevalence of infection, modes of transmission, economics of infection and preventative measures to block the infection process have been discussed.

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“…Over-the-counter H2RAs doses (ranitidine 75 mg, famotidine 10 mg), are less than those listed in the prescription product insert, however, at these doses they are effective in reducing overnight gastric acidity for 12 h [61], as well as blunting the food-stimulated gastric response [62,63]. They are also effective in the treatment of symptomatic GERD [47].…”

Section: Drugs Modulating Gastric Acidmentioning

confidence: 99%

Acid peptic diseases: pharmacological approach to treatment

Mejia

Kraft

2009

Expert Review of Clinical Pharmacology

105

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Acid peptic disorders are the result of distinctive, but overlapping pathogenic mechanisms leading to either excessive acid secretion or diminished mucosal defense. They are common entities present in daily clinical practice that, owing to their chronicity, represent a significant cost to healthcare. Key elements in the success of controlling these entities have been the development of potent and safe drugs based on physiological targets. The histamine-2 receptor antagonists revolutionized the treatment of acid peptic disorders owing to their safety and efficacy profile. The proton-pump inhibitors (PPIs) represent a further therapeutic advance due to more potent inhibition of acid secretion. Ample data from clinical trials and observational experience have confirmed the utility of these agents in the treatment of acid peptic diseases, with differential efficacy and safety characteristics between and within drug classes. Paradigms in their speed and duration of action have underscored the need for new chemical entities that, from a single dose, would provide reliable duration of acid control, particularly at night. Moreover, PPIs reduce, but do not eliminate, the risk of ulcers in patients taking NSAIDs, reflecting untargeted physiopathologic pathways and a breach in the ability to sustain an intragastric pH of more than 4. This review provides an assessment of the current understanding of the physiology of acid production, a discussion of medications targeting gastric acid production and a review of efficacy in specific acid peptic diseases, as well as current challenges and future directions in the treatment of acid-mediated diseases.

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Initial management strategies for dyspepsia

Cited by 66 publications

References 59 publications

Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

Helicobacter pylori infection in developing countries: The burden for how long?

Acid peptic diseases: pharmacological approach to treatment

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