Initial Management Protocols for New-Onset Dyspepsia: Step-Up Versus Step-Down

Setting and participants. 664 patients aged ≥ 18 years who presented to their primary care provider in the Netherlands for new-onset dyspepsia between 2003 and 2006. Patients were assigned to either step-up or step-down therapy. Step-up therapy started with antacids, switched to H2-receptor antagonists, and then ended with proton pump inhibitors (PPIs). Step-down therapy employed the same medications as step-up therapy but in reverse order, from PPIs to antacids. Each step lasted 4 weeks, and subsequent steps were only started if symptoms persisted or relapsed. Dyspepsia was defined as upper abdominal pain or discomfort that was determined by the primary care provider to originate from the upper gastrointestinal tract. Patients were excluded if they had an endoscopy within the prior year, used acid-suppressive medications within the previous 3 months, had alarm symptoms (dysphagia, unintended weight loss, anemia, or hematemesis), were pregnant, or had limited literacy. Direct and indirect medical and societal costs were calculated (eg, medication costs, consultations, diagnostic tests, productivity loss).