Gastroenterology

Gastroenterology

Volume 127, Issue 5, November 2004, Pages 1329-1337
Gastroenterology

Clinical-alimentary tract
The efficacy of proton pump inhibitors in nonulcer dyspepsia: A systematic review and economic analysis

https://doi.org/10.1053/j.gastro.2004.08.026Get rights and content

Background & Aims: The evidence that proton pump inhibitor (PPI) therapy affects symptoms of nonulcer dyspepsia is conflicting. We conducted a systematic review to evaluate whether PPI therapy had any effect in nonulcer dyspepsia and constructed a health economic model to assess the cost-effectiveness of this approach. Methods: Electronic searches were performed using the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and SIGLE until September 2002. Dyspepsia outcomes were dichotomized into cured/improved versus same/worse. Results were incorporated into a Markov model comparing health service costs and benefits of PPI with antacid therapy over 1 year. Results: Eight trials were identified that compared PPI therapy with placebo in 3293 patients. The relative risk of remaining dyspeptic with PPI therapy versus placebo was .86 (95% confidence interval, .78–.95; P = .003, random-effects model) with a number needed to treat of 9 (95% confidence interval, 5–25). There was statistically significant heterogeneity between trials (heterogeneity χ2 = 30.05; df = 7; P < .001). The PPI strategy would cost an extra $278/month free from dyspepsia if the drug cost $90/month. If a generic price of $19.99 is used, then a PPI strategy costs an extra $57/month free from dyspepsia. A third-party payer would be 95% certain that PPI therapy would be cost-effective, provided they were willing to pay $94/month free from dyspepsia. Conclusions: PPI therapy may be a cost-effective therapy in nonulcer dyspepsia, provided generic prices are used.

Section snippets

Search strategy

Trials were identified from the Cochrane Controlled Trials Register (September 2002), MEDLINE (1966 to September 2002), EMBASE (1988 to September 2002), and CINAHL (1982 to September 2002), and the gray literature (eg, conference reports, technical reports, and dissertations) was searched using SIGLE. Details of the search strategy used for each database are published in the Cochrane Library.8 For example, for MEDLINE, patients with dyspepsia were identified with the medical subject heading and

PPI therapy versus placebo

A total of 11,796 citations were reviewed. Six eligible papers (reporting 8 trials)6, 7, 22, 23, 24, 25 were identified that compared PPI therapy with placebo in 3293 patients (Table 2). (For reference 22, data from the authors and TAP Pharmaceutical Products US were provided to separate trials M96 and M97.) Four papers (reporting 6 trials)6, 7, 22, 23 provided evaluable data to compare low- and standard-dose PPI therapy in 2032 patients. There was no statistically significant difference

Discussion

This is the first systematic review evaluating the efficacy of PPI therapy in NUD. We have shown that PPIs have a small but statistically significant effect on symptoms of NUD. This suggests that a modest proportion of patients with NUD have an acid-related disorder. There may be increased acid sensitivity in patients with NUD,28 because duodenal acidification has been shown to increase sensitivity to gastric distention.29 Studies have suggested, however, that peak and basal acid secretion in

References (41)

  • M. Tebaldi et al.

    Clinical economics reviewfunctional non-ulcer dyspepsia

    Aliment Pharmacol Ther

    (1998)
  • B.C. Delaney et al.

    Dyspepsia. Health care needs assessment 3rd series

    (2003)
  • N.J. Talley

    Review articleshould treatment be targeted on disturbed physiology?

    Aliment Pharmacol Ther

    (1995)
  • P.G. Farup

    Functional dyspepsia and gastric acidany relation?

    Scand J Gastroenterol

    (2002)
  • N.J. Talley et al.

    Efficacy of omeprazole in functional dyspepsiadouble-blind, randomized, placebo-controlled trials (the Bond and Opera studies)

    Aliment Pharmacol Ther

    (1998)
  • W.M. Wong et al.

    Double blind, randomised, placebo controlled study of four weeks of lansoprazole for the treatment of functional dyspepsia in Chinese patients

    Gut

    (2002)
  • P. Moayyedi et al.

    Pharmacological interventions for non-ulcer dyspepsia

    Cochrane Database Syst Rev

    (2003)
  • N.J. Talley et al.

    Functional dyspepsiaa classification with guidelines for diagnosis and management

    Gastroenterol Int

    (1991)
  • N.J. Talley et al.

    Functional gastroduodenal disorders

    Gut

    (1999)
  • Management of dyspepsiareport from a working party

    Lancet

    (1988)
  • Cited by (213)

    View all citing articles on Scopus

    B.C.D. is supported by a UK National Health Service R&D Primary Care Career Scientist Award.

    View full text