Managing dyspepsia without alarm signs in primary care: new national guidance for England and Wales

Aim: To report new recommendations for the primary care management of dyspepsia without alarm signs in England and Wales. Method: An independent, representative group of health care professionals, patient representatives and researchers developed the guideline using evidence-based and small group-working principles, and incorporated extensive peer-reviewing and feedback from stakeholder organizations. Results: Referral to investigate dyspepsia should be made for alarm signs and not on the basis of age alone, reflecting the balance of benefit and harm from endoscopy. Empirical management without formal diagnosis is appropriate for most patients: reviewing patient history, lifestyle, over-the-counter medicines, and providing a course of proton-pump inhibitors and/or Helicobacter pylori test and treatment. Patients with ongoing symptoms require at least annual review to discuss symptoms and lifestyle, and as appropriate, encourage stepping down prescribed medication and returning to self-care. A new strategy included in the step down process is the use of therapies 'on-demand'. Conclusion: The guideline provides structured and supported recommendations for both undiagnosed and endoscopically investigated dyspepsia. Some favour increased investigation to detect Barrett's oesophagus and carcinoma. However, there is inconclusive evidence that patients without alarm signs will benefit subsequently from endoscopy, while investigation involves a small but real risk of harm.