Management of Dyspepsia in the Primary Care Setting

By Kevin O. Hwang, MD, MPH

Topline: Testing and treating for Helicobacter pylori is the best strategy for managing dyspepsia symptoms in the primary care setting, although patients may prefer prompt endoscopy, according to a network meta-analysis.

Key points

1. “Test and treat” for H. pylori was the best strategy for managing symptoms, followed closely by prompt endoscopy
2. “Test and treat” resulted in fewer endoscopies than all other strategies except symptom-based management
3. Patients preferred the strategy of prompt endoscopy

Dyspepsia is a common complaint manifesting with symptoms such as upper abdominal pain or discomfort, heartburn, regurgitation, and nausea. The global prevalence of dyspepsia is approximately 21% (1). For patients without alarm symptoms (e.g. dysphagia, weight loss, or anemia), there is no clear consensus on the best strategy for initial management.

Therefore, Eusebi and colleagues conducted a systematic review and network meta-analysis of strategies for managing dyspepsia in the primary care setting (2). The study included 15 randomized controlled trials (mostly in Europe) with 6,162 adult participants (age ≥ 18 years) with previously uninvestigated dyspepsia. The strategies examined were:

1. Prompt endoscopy; n=1,942
2. Test for H. pylori and followed by endoscopy if positive; n=484
3. Test for H pylori followed by treatment if positive (“test and treat”); n=1,938
4. Empirical acid suppression; n=1,329
5. Symptom-based management; n=469

In the primary outcome with intention-to-treat analysis, “Test and treat” ranked first for symptom management, with a relative risk of 0.89 (95% confidence interval 0.78 to 1.02) for remaining symptomatic after at least 12 months of follow up. Prompt endoscopy was ranked a close second with relative risk 0.90 (95% confidence interval 0.80 to 1.02). The probability of “test and treat” or prompt endoscopy being the most effective symptom management strategy was estimated at 79% and 71%, respectively. However, with wide confidence intervals, no strategy was significantly less effective than “Test and treat.”

Symptom-based management and “Test and treat” were the most likely to reduce endoscopy use. Prompt endoscopy was the least likely to cause patient dissatisfaction with management. The rate of upper gastrointestinal cancer detection across all strategies was only 0.40%.

The main strength of the study was the use of network meta-analysis, which allowed indirect comparisons of treatments that were not directly compared in the individual trials, yielding a ranking of multiple strategies. Other strengths were the intention-to-treat analysis of patient symptoms at 12 months as well as generalizability to the primary care setting.

A limitation of the study was the lack of patient blinding due to the pragmatic design of the trials. Additionally, 14 of 15 trials were conducted in Europe and 1 in Asia, such that applicability to dissimilar settings may need to be evaluated.

Although patients appeared to prefer prompt endoscopy, the authors note that the associated costs, along with the low rate of upper gastrointestinal cancer, should raise questions about the benefit of prompt endoscopy for uninvestigated dyspepsia in patients without alarm symptoms. The authors also note that in a “Test and treat” approach, non-invasive detection of H. pylori with urea breath test or fecal antigen test should be followed automatically by treatment.

References

1. Ford AC, Marwaha A, Sood R, et al. Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis. Gut 2015;64:1049–1057. http://dx.doi.org/10.1136/gutjnl-2014-307843
2. Eusebi LH, Black CJ, Howden CW, Ford AC. Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis. BMJ 2019;367:l6483. https://doi.org/10.1136/bmj.l6483