Editor,—I was interested to read the paper by Eggleston et al (Gut1998;42:13–16) purporting to show that a “step up” approach using prokinetics and H₂ receptor antagonists in the management of gastro-oesophageal reflux disease (GORD) is more cost effective than omeprazole in a general practice setting. I do not think the conclusions drawn are supported by data presented.

The MediPlus database does not permit systematic evaluation of the severity of GORD symptoms and so there is no certainty that the three patient groups (who received omeprazole, ranitidine or cisapride) were comparable. Patients were excluded from the study if they had initially been referred to hospital (<13%) because they were regarded as suffering from “more complicated GORD”. No evidence is presented for this assertion. It is well recognised that there is no correlation between the severity of a patient’s symptoms and the extent of any oesophagitis.1-3 The fact that patients on omeprazole received more prescriptions in the six month study period (2.96) than those on cisapride (1.85) is further evidence that the groups were not clinically comparable. Cisapride is known to be relatively ineffective4 in the treatment of GORD symptoms.

The paper makes no evaluation of clinical success, basing the evaluation entirely on cost with the implicit assumption of equivalence in clinical efficacy between omeprazole, ranitidine and cisapride, which many other controlled studies have shown not to be the case.

The conclusions drawn by the authors are also flawed. They have provided no evidence that the “stepped approach” is appropriate in GORD. Many studies have confirmed that omeprazole is more cost effective.5-9 The recent reduction in the price of omeprazole makes this cost advantage even greater.

The conclusion, “such chronic dependence on drug therapy appears to be a particular problem with. . .omeprazole and represents a further argument in favour of a step up approach aimed at initially targeting prescribing of this powerful drug on a highly selected patient group”, is not supported by the evidence from the study nor by references. Moreover, the keenness of patients to take omeprazole is a reflection of its effectiveness. Given the central role of gastric acid in GORD reducing oesophageal exposure to this corrosive agent is a rational approach to the management of this disease. Antacid/alginate combinations provide short lived symptom relief. The H₂receptor antagonists and cisapride have some efficacy in treating GORD but there is now abundant evidence in the literature to show that proton pump inhibitors are the most effective agents in this disease.

Unlike the H₂ receptor antagonists, proton pump inhibition does not suffer from the drawback of tolerance, and omeprazole heals regardless of the grade of oesophagitis on entry. Symptom resolution with omeprazole is a better indicator of healing of any underlying oesophagitis than with H₂ receptor antagonists.

In conclusion, treatment with proton pump inhibitors provides cost effective management across the GORD spectrum, resolves patients symptoms, improves their quality of life and heals the underlying pathology, preventing the development of complications such as stricture, and reducing hospital referrals.