A Cochrane review [Abstract] 1 [withdrawn from publication] included 25 studies reporting 27 comparisons. Proton pump inhibitors were significantly more effective than both H2 receptor antagonists (RR 0.63, 95% CI 0.47 to 0.85) and antacids (RR 0.72, 95% CI 0.64 to 0.80). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).
A systematic review including 21 studies, of which 5 trials with 1585 patients (3 RCTs) assessed the effect of endoscopy on patient outcomes, was abstracted in DARE 2. The three RCTs (which scored either 2 or 3 on the Jadad score) reported no difference in symptoms in the endoscopy group compared with empiric H2 antagonist therapy or upper gastrointestinal radiography after 6 months or one year. One RCT reported increased satisfaction and fewer sick leave days with prompt endoscopy compared to ranitidine. Three RCTs assessing resource utilization reported conflicting results. Five studies reported empiric Helicobacter pylori therapy and the test-and-treat strategy to be of greater cost-effectiveness or cost utility than initial endoscopy and one study reported no difference in costs between strategies. Some models were sensitive to the cost of endoscopy and medical therapy.
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