We made some changes in our statement, one by moving proton pump inhibitors above H2 blockers. I believe that they provide the most rapid symptom relief in the highest percentage of patients. H2 blockers still work in a lot of patients and they are effective in patients with less severe reflux disease. This is an important concept. I think that when you are walking all factors would indicate this to be a cost effective approach.
Combination therapy is very expensive.
We see a lot of patients who come to us on a combination of H2 blockers and a promotility agent. I really don't believe in combination therapy for reflux except for the bloated, dyspeptic patient who may benefit somewhat from a protmotility agent and somewhat from an acid blocker. The combination of a proton pump and a promotility agent is actually even more expensive and the efficacy does not quite reach that of b.i.d. The PPI's are the way to go in most patients. Whether you step up or step down therapy remains poorly understood, even from the cost effective standpoint.