Step up vs step down

Which is more effective for treating dyspepsia: Starting with aggressive therapy and tapering down, or starting with antacids and progressing to more aggressive therapy depending on symptoms? The so called step-up vs step-down debate has raged for years, particularly in managed-care settings. In a new study from the Netherlands, patients with dyspepsia were randomized to treatment with an antacid, H2-receptor antagonist, and proton pump inhibitor (step up) vs the same drugs in reverse order (step down), with each step lasting 4 weeks. Primary outcome was symptom relief and cost-effectiveness of initial management at 6 months. Treatment success after 6 months was achieved in 72% of patients in the step-up group and 70% of patients with step-down group. The average medical costs were lower for patients in the step-up group (€228 vs €245; P = 0.0008) mainly because of the cost of medication. The rate of adverse effects was the same in both groups and were generally mild. The authors suggest that treatment success is similar in both groups but the step-up strategy was more cost-effective for patients with new onset dyspeptic symptoms (van Marrewijk CJ, et al. Lancet 2009;373:215-225). An accompanying editorial suggests that the degree of cost difference between the two groups was overestimated because costs were based on brand name drugs and generics are now available. It furthers suggested that the study may not change practice in primary care as the author recommends a 4-8 week course of a proton pump inhibitor for patients with symptoms of the upper gastrointestinal tract with discontinuation of treatment if patients remain asymptomatic (van Zanten SV. Lancet 2009;373:187-189).