Test-and-treat gaining acceptance in dyspepsia
National Prescribing Service Limited ACN 082 034 393
An independent, Australian organisation for Quality Use of Medicines
ISSN 1441-7421 April 2004
Most people with GORD can be identified by the presence of heartburn or acid regurgitation as their predominant symptom. However, for people with other causes of dyspepsiac , symptoms do not reliably predict diagnosis. Empirical therapy is used as a more costeffective method of guiding dyspepsia management than endoscopy, but the choice of empirical therapy is a matter of debate. Previously, a trial with a PPI or H2 antagonist has been recommended. Evidence for the test-and-treat approach has emerged more recently. In the test-and-treat approach, people who present with dyspepsia (excluding those with suspected GORD, NSAID users and people with indications for immediate endoscopy, see Figure 2) are given a non-invasive testd for Helicobacter pylori: those who test positive receive eradication treatment while uninfected people receive a trial of a standard-dose PPI or H2 antagonist. People whose symptoms persist can then be referred for specialist management.
The test-and-treat approach appears to be as effective as early endoscopy for determining management of dyspepsia22 and may improve symptoms and reduce rates of referral for endoscopy more than empiric PPI therapy.23 This approach means that people with underlying peptic ulcer disease receive appropriate therapy without the need for endoscopy. However, people without peptic ulcer disease, in whom the benefits are less certain, will also receive eradication therapy. Possible advantages of this include24: achieving symptom resolution in a small proportion of people with non-ulcer dyspepsia25 removing a risk factor for future peptic ulcer disease and gastric cancer preventing gastric mucosal changes that may predispose to cancer in long-term PPI users infected with H. pylori. (Some guidelines suggest that eradication therapy be considered for long-term PPI users2,26, although evidence for a benefit is currently lacking.)
Potential disadvantages include the development of resistance with wider use of eradication therapy and the occurrence of complications such as antibioticinduced pseudomembranous colitis. It has also been suggested that eradication therapy exacerbates or causes reflux symptoms but it is generally accepted that this is unlikely.2,26
To date, evidence for the test-and-treat strategy comes from secondary-care settings and little cost-effectiveness information is available; studies are underway to address these issues.22 Despite these limitations, several guidelines now recommend the test-and-treat approach.24,26–28
http://www.nps.org.au/__data/assets/pdf_file/0016/15820/news33_PPIs_0404.pdf
