Proton pump inhibitors (PPIs) commonly are used to treat gastroesophageal reflux disease. Nonulcer dyspepsia, a diagnosis made in symptomatic patients with negative endoscopy, seems less susceptible to treatment with PPIs. Because PPIs are available over the counter, they are likely being used for a variety of upper gastrointestinal symptoms.

Moayyedi and associates conducted a systematic review using Cochrane Collaboration methodology to evaluate the effect of PPI therapy on nonulcer dyspepsia with the hypothesis that over-the-counter availability may make PPIs cost-effective in managing upper gastrointestinal symptoms. Studies of PPI use in patients with nonulcer dyspepsia that included a comparison group treated with placebo or some other therapeutic agent and that assessed symptoms of dyspepsia as the outcome were included. Health economic analyses were performed using a Markov model.

PPI therapy had a small but statistically significant positive effect on symptoms of nonulcer dyspepsia, hinting that at least some patients with this condition have an acid-related disorder. Symptom response appeared the same in Helicobacter pylori-positive and H. pylori-negative patients with nonulcer dyspepsia. Increasing the PPI dose did not have an additional benefit. Eradication of H. pylori also had similarly small beneficial effects on symptoms.

The authors conclude that although PPI therapy has a modest effect on symptoms of nonulcer dyspepsia, it appears cost-effective in this condition because generic preparations are available over the counter at lower prices and symptom resolution might decrease the need for further investigations. The cost-effectiveness is even greater if PPIs are reserved for patients with epigastric or reflux symptoms rather than patients with dysmotility.