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▸ van Marrewijk CJ, Mujakovic S, Fransen GAJ, . Effect and cost-effectiveness of step-up versus step-down treatment with antacids, H2-receptor antagonists, and proton pump inhibitors in patients with new onset dyspepsia (DIAMOND study): a primary-care-based randomised controlled trial. Lancet 2009;373:215–25.

The initial management of uninvestigated dyspepsia has been the subject of numerous pragmatic randomised controlled trials over the last 15 years. Individual patient data meta-analyses of these trials have demonstrated that prompt endoscopy is superior to Helicobacter pylori “test and treat” in terms of symptom relief, but is not cost-effective, and that there is little to choose between “test and treat” and empirical acid-suppression therapy (AST) with a proton pump inhibitor (PPI), in terms of both symptoms and costs. Now van Marrewijk and colleagues demonstrate that first-line AST does not necessarily mean a PPI.

Subjects with new-onset dyspepsia were recruited in primary care and randomised to receive 1 month of AST either as step-up from antacid to H2-receptor antagonist (H2RA) to PPI (if symptoms were not adequately relieved or relapsed), or step-down with the reverse approach applied. If therapy was a success, it was …

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