‘Test and treat’ effective, but not preferred by patients, for uninvestigated dyspepsia, review and meta-analysis finds

Testing for Helicobacter pylori and eradication treatment in those who tested positive (“test and treat”) was ranked first for efficacy among methods of managing uninvestigated dyspepsia, although it performed similarly to prompt endoscopy and was not superior to the other strategies, a systematic review and network meta-analysis found.

Researchers reviewed 15 randomized controlled trials involving 6,162 adults that assessed the effectiveness of management strategies for uninvestigated dyspepsia. Strategies included “test and treat,” prompt endoscopy, H. pylori testing and endoscopy in those who tested positive, empirical acid suppression, and symptom-based management. Final follow-up was at 12 months or longer, and strategies were ranked according to P value. The study results were published Dec. 11 by The BMJ.

“Test and treat” ranked first (relative risk [RR], 0.89; 95% CI, 0.78 to 1.02; P=0.79), while prompt endoscopy ranked second but performed similarly (RR, 0.90; 95% CI, 0.80 to 1.02; P=0.71). None of the strategies examined were significantly less effective than “test and treat.” Patients assigned to “test and treat” were significantly less likely to receive endoscopy (RR, 0.23; 95% CI, 0.17 to 0.31; P=0.98) than those assigned to all other strategies, except symptom-based management (RR, 0.60; 95% CI, 0.30 to 1.18). Patients who received prompt endoscopy had significantly lower dissatisfaction than those who received “test and treat” (RR, 0.67; 95% CI, 0.46 to 0.98) and empirical acid suppression (RR, 0.58; 95% CI, 0.37 to 0.91). Upper gastrointestinal cancer rates were low in all trials.

“Test and treat” led to fewer endoscopies than all other approaches, except symptom-based management, but patients preferred prompt endoscopy as a management strategy for their symptoms, the authors concluded. Individual trials had a high risk for bias, and access to individual-patient data was not available, among other limitations, they said.

“Dyspepsia, however defined, is a frequent reason for consultation with primary care providers and gastroenterologists,” the authors wrote. “Dyspeptic symptoms can cause substantial anxiety for patients who might fear that they have a serious underlying condition to account for their symptoms. This anxiety is despite the fact that upper gastrointestinal malignancy is identified at endoscopy in less than 1% of patients.”

The authors noted that although “test and treat” performed best in this analysis and is recommended by guidelines, it may not necessarily be preferred by patients. “Management of patients with dyspepsia should continue to be based on best evidence, but should also take into account the nuances of the individual patient within the confines of the healthcare setting,” they wrote.