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(. to .)). Secondly, the increased threat was not observed to the same extent with all classes of antidepressants but mostly with selective serotonin reuptake inhibitors. Thirdly, if depression were secondary to peptic ulcer the danger of bleeding would revert to the baseline value immediately after the very first fewHeartburn treatment in major carePrescribing omeprazole would conflict with wish to handle prescribing fees EditorHatlebakk et al recommend that omeprazole mg when day-to-day ought to be considered as a initially decision when patients with heartburn are being treated in major care. With the formation of major care groups all Title Loaded From File common practitioners are coming below escalating stress to control prescribing fees. If fees are exceeded in a single price range, budgets in other clinical regions (including employees, including practice nurses) could be threatened. I and my colleagues inside the practice have worked challenging over two years to conBMJ VOLUME May bmj.comLetterstrol our prescribing expenses. Omeprazole was the largest single gastrointestinal drug cost, accounting for of our total drug spending budget and just over half of our gastrointestinal drug charges. Hatlebakk et al make no mention of lifestyle advicesuch as tips on smoking, eating plan, and weight reductionas a process of controlling symptoms. Recent recommendations from our main care group (through the principal care investment program) recommend that we must target the use of proton pump inhibitors, and this will be linked to an element of payment that we get under the prescribing incentive scheme. Increasingly we are making use of histamine receptor antagonists each as first line treatment of symptomatic reflux and as intermittent maintenance remedy. We are going to seek out considerable conflict in following Hatlebakk et al’s suggestions.Alexander Williams general practitioner St Thomas Overall health Centre, Exeter EX HJ firstname.lastname@example.org Competing interestsDr Williams’s practice receives a study and improvement grant from South and West Regional Health Authority. Hatlebakk JG, Hyggen A, Madsen PH, Walle PO, Schulz T, Mowinckel P, et al. Heartburn therapy in primary carerandomised double blind study for weeks. BMJ ;:. (August.)Step up approach to management is very best EditorHatlebakk et al’s study supports the empirical therapy of heartburn inside a key care setting. But the authors’ conclusion that “omeprazole really should be regarded as a very first decision when treating patients with heartburn in major care” is unsupported by their findings that a proton pump inhibitor is additional powerful than cisapride inside the empirical treatment of heartburn. Because of the massive expense of proton pump inhibitors towards the NHS we favour the step up strategy to managing sufferers with heartburn in key care. Tips on way of life and use of antacids must be offered initially, and H antagonists and proton pump inhibitors must be offered only for patients with unresolved symptoms.Sonia Saxena research fellow Department of Basic Practice, St George’s Hospital Medical School, London SW RE email@example.com Richard C G Pollok study fellow Digestive Illnesses Analysis Centre, St Bartholomew’s as well as the Royal London College of Medicine and Dentistry, London E AT FundingSS South Thames Research and Development Fund, RP WellcomeTrust Competing interestsNone declared. Hatlebakk JG, Hyggen A, Madsen PH, Walle PO, Schulz T, Mowinckel P, et al. Heartburn remedy in major carerandomised double blind study for weeks.