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Antacids Are Best First Choice for Indigestion

Study finds they're a bit cheaper than more potent drugs like PPIs

THURSDAY, Jan. 15 (HealthDay News) -- Starting treatment for dyspepsia -- the medical name for indigestion -- with run-of-the-mill antacids, then moving up to more sophisticated drugs if needed, is slightly less costly than starting with the more powerful drugs, a new study says.

"Most patients with new-onset dyspepsia are treated with empirical proton pump inhibitor treatment [meaning that treatment decisions are based on observation more than testing] all over the world, [making] proton pump inhibitors one of the most prescribed drugs worldwide, with enormous cost for society," noted study senior author Dr. Robert Laheij, of the department of gastroenterology at Radboud University Nijmegen Medical Centre in the Netherlands.

But he added that, "overall, most patients with dyspepsia could and should be managed with antacids and H2 receptor antagonists instead of treatment with proton pump inhibitors. Treatment with proton pump inhibitors should be reserved for those not responding to antacids or H2 receptor antagonists."

Proton pump inhibitors include such brand-name drugs as Prilosec, Prevacid and Nexium.

But the cost difference noted in the study was "tiny," said Dr. Maria T. Abreu, a professor of medicine and chief of gastroenterology at the University of Miami Miller School of Medicine. And given that the effects were about the same, "this is nothing terribly exciting," she said. "A lot of people were going to get better no matter what you did."

The study findings were published in the Jan. 17 issue of the journal The Lancet.

Proton pump inhibitors, H2-receptor antagonists and regular old antacids can all treat indigestion in its various forms. But guidelines on how to use these drugs are inconsistent, the study authors said.

Complicating matters is the fact that there's no uniform definition for indigestion, which has a diverse array of symptoms and possible causes.

For this study, 664 patients aged 18 years and older who had consulted with their family doctor for newly occurring indigestion were randomly selected to join one of two treatment groups. The "step-up" therapy involved initial treatment with antacids, then H2-receptor antagonists and finally proton pump inhibitors (PPIs), if needed. The "step-down" approach was just the opposite: PPIs first, then working down to antacids. Each treatment lasted four weeks, and patients only graduated to the next step if they continued to have symptoms.

Treatment success was similar in both groups: 72 percent for those doing the step-up approach and 70 percent for those doing step-down. Side effects, all minor, were also nearly equivalent.

The average medical costs were 228 Euros ($299) for those in the step-up group and 245 Euros ($322) in the step-down group. The difference was mainly due to the cost of medication, the study authors said.

The difference in cost-effectiveness, the authors noted, narrowed when generic prices were used. PPIs are now available in any Costco store, Abreu said.

An accompanying editorial by Dr. Sander Veldhuyzen van Zanten, of the division of gastroenterology at the University of Alberta, Canada, noted that in "real life," doctors would rarely step down if there wasn't an initial response to PPIs.

"What can't be forgotten for people with this abdominal discomfort that aren't getting better with even PPIs, [is that] those are the group of people who merit further investigation to make sure they don't have some significant pathology," Abreu said.

More information

The American Academy of Family Physicians has more on indigestion.

SOURCES: Robert Laheij, M.D., Ph.D., department of gastroenterology, Radboud University Nijmegen Medical Centre, the Netherlands; Maria T. Abreu, M.D., professor of medicine and chief, division of gastroenterology, University of Miami Miller School of Medicine; Jan. 17, 2009, The Lancet

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