Orientação inicial da dispepsia ao nível dos cuidados de saúde primários. Revisão sistemática

Introduction: The initial management of dyspepsia on a primary health level is controversial. It is estimated that 4 out of 10 adults present per year a new or a first episode of dyspepsia, and 1 out of 10 visits his/her doctor. Many patients that perform an upper digestive endoscopy (UDE) do not report significant findings. The aim of this work is to determine, based on scientific evidence, which primary health strategies present the best trade-off cost-effectiveness for the initial management of patient with dyspepsia. Methodology: A systematic review was conducted on several sources: MEDLINE®, The Cochrane Library, Bandolier, Medscape®, TRIP database, DARE, EBM Resources and Preventive Services, of papers published between 1985 and May 2005. Randomized Clinical Trials (RCT) that benchmark different initial strategies were performed. Five RCTs were included for a comparison of «initial UDE» versus «empirical treatment», four RCTs for a comparison of «test for Helicobacter pylori (H. pylori) and its eradication («test and treat»)» versus « pharmacology intervention», and four RCTs for trading-off «»test and treat» strategy» versus «UDE». Three meta-analyses (one still to be published), and eight guidelines and one review based on scientific evidences were reviewed. Results: Five RCTs (n = 1473) that compared the initial UDE to the empirical treatment demonstrate a non-significant reduction of recurrence risk of dyspeptic symptoms. In four RCTs (n = 1863), the initial UDE strategy showed a small clinical benefit, but statistically significant, when compared to the «test and treat» strategy; nevertheless, the incurred costs were higher. In four RCTs (n = 1056) where the «test and treat» strategy was benchmarked against the empirical treatment, the clinical benefit was proved to be statistically significant, without cost differences. In addition, guidelines based on scientific evidences of various societies were reviewed and compared, along with recommendation forces. Discussion/Conclusion: The initial management of «Helicobacter pylori (H. pylori) and its eradication » test presents a best trade-off cost-effectiveness than that of strategies that involve UDE or initial prescription; on the other hand, the empirical treatment was more advantageous on the «cost-effectiveness» relationship that the initial UDE. The latter is not recommended as a first line of approach to patients with dyspepsia without alarm symptoms. A decision making algorithm, enriched with recommendation levels, is presented.