Should we step-up or step-down in the treatment of new-onset dyspepsia in primary care?

Dyspepsia is common in the community, and the condition represents a considerable burden to the health service. Individuals over the age of 50 to 55 years consulting with new-onset dyspepsia and those with alarming features, such as dysphagia and weight loss, require urgent endoscopy to exclude gastro-esophageal malignancy. For younger individuals without alarm features prompt endoscopy and "test and scope" are not cost-effective initial management strategies. "Test and treat" or empirical acid suppression therapy should be preferred, depending on patient and physician choice, as well as local prevalence of Helicobacter pylori. If empirical acid suppression therapy is favored, a recent primary care-based trial from the Netherlands suggests the choice of initial acid suppressant (antacid or proton pump inhibitor [PPI]) has little effect on the likelihood of remaining symptomatic, and that stepping-up from antacid to PPI is more cost-effective than stepping-down from PPI, when current prices of branded drugs were considered.