Functional dyspepsia: bye-bye to PPIs

Absence of therapeutic benefit of proton pump inhibitor therapy among Chinese patients with functional dyspepsia When specifically asked, a significant proportion of the adult population reports dyspepsia—that is, pain or discomfort in the upper abdomen. The prevalence reported in the literature varies from 25% to 30%. Although only one in four patients with dyspepsia in the UK and USA sees a doctor for their symptoms1–4 dyspepsia accounts for up to 5% of consultations in family practice.5 When appropriately investigated, less than half have an underlying structural explanation for symptoms such as peptic ulcer or reflux oesophagitis. The remainder are classified as having functional dyspepsia. The vast number of patients with functional dyspepsia, and the usually chronic or recurrent nature of this ailment, creates an enormous market for the drug industry. In spite of the obvious difficulties in delimiting the patient population, and the absence of hard end points, a fair number of—mostly industry initiated—controlled trials have been conducted. However, regardless of whether the target has been gastric acid, gastrointestinal dysmotility, or Helicobacter pylori , the treatment effects have generally been unimpressive, and similar to the usually strong effects observed with placebo alone. Although meta-analyses6–8 seem to indicate an approximately 20–30% advantage for acid suppression therapy (H2 receptor antagonists or proton pump inhibitors (PPIs)) over placebo in functional dyspepsia, the value of these secondary publications may be limited due to possible publication bias and various imperfections in the studies included. The main concern is the admixture of patients with non-erosive gastro-oesophageal reflux disease (GORD), which is known to respond to acid suppressive treatment.9 As large studies are unlikely to remain unpublished even in the event of a negative result, it appears well advised to focus on such studies. It also …