PPI or Testing for Helicobacter pylori as the First Step for Patients Presenting with Dyspepsia?
Abstract & Commentary
By Malcolm Robinson MD, FACP, FACG, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. Robinson serves as a consultant for TAP, Pfizer, Janssen, Eisai, J&J-Merck, and Procter & Gamble, is on the speaker's bureau of Janssen, Eli Lilly, Solvay, TAP, and Aventis, and does research for Forest Labs, Wyeth-Ayerst, AstraZeneca, and Centocor.
Synopsis: Testing and treating H. pylori and empirical PPI treatment similarly relieved symptoms in dyspeptic patients, but the 'test and treat' strategy resulted in lower endoscopic workload and decreased cost.
Source: Jarbol DE, et al. Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspepsia? A cluster-randomized trial. Am J Gastroenterol. 2006;101:1200-1208.
Management of dyspepsia in primary care could involve prompt endoscopic evaluation, 'testing and treating' H. pylori, or prescription of empirical anti-secretory therapy. Because discovery and eradication of H. pylori might obviate recurrent peptic ulcer disease (PUD) in populations where PUD is prevalent, many guidelines recommend testing for H. pylori followed by eradication of the organism when it is found. However, most practitioners do not follow such guidelines, and scientific support for this approach has been less than compelling. Most authorities agree that 'test and treat' provides comparable benefits vs. prompt endoscopy, but the comparative utility of initial PPI treatment is less well defined. The present government-funded study was done in 106 general practices in one Danish county (population 472,000) between 2001 and 2003. 250 patients were enrolled in each of 3 groups.
The three strategies employed were: a) esomeprazole 20 mg b.i.d. for one week; b) H. pylori testing followed by treatment for positive cases; c) esomeprazole 20 mg b.i.d. for one week followed by 'test and treat' approach if symptoms recurred. H. pylori testing involved the use of the well-validated 13-C urea breath test (in patients who had had no PPI treatment for at least one week). Eradication therapy was esomeprazole 20 mg, amoxicillin 500 mg, and clarithromycin 500 mg, all given twice daily for a week. (This regimen is not approved in the United States). Diary cards querying GI symptoms and quality of life were mailed to all participants monthly for one year. 87% of patients completed all diaries. Symptom control and quality of life at 1 year didn't differ between treatment groups. More endoscopies were done in the PPI recipients than in either other group. The authors agreed that recruitment bias could have occurred between and among the various practice clusters. Many of these patients had reflux symptoms in addition to dyspepsia (epigastric discomfort), and the initial presence of GERD-type symptoms led to more PPI use during follow-up. This population had 24% of patients found to be H. pylori-positive. The authors admitted that their results could be affected if reflux were to worsen in patients whose H. pylori infection was eradicated or if such patients subsequently were shown to have antibiotic resistant infections.
Commentary
This study has many peculiarities. It is hard to understand why the authors chose a single week of PPI therapy as one arm of the study since this is not the standard of care anywhere in the world. In most US populations, the prevalence of H. pylori would be lower than found in this Danish study. This would make the potential benefit from a 'test and treat' strategy. The real universal answer is not yet 'in' for the utility of testing for H. pylori in dyspeptic patients since populations not only differ in rates of H. pylori infection but also in the virulence of whatever strains happen to be present. In places wh ere peptic ulcer disease due to H. pylori is still relatively common, 'test and treat' may still be a perfectly valid therapeutic option. Such favorable results are far less likely in most North American populations.
Testing and treating H. pylori and empirical PPI treatment similarly relieved symptoms in dyspeptic patients, but the 'test and treat' strategy resulted in lower endoscopic workload and decreased cost.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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