Helicobacter pylori and Functional Dyspepsia: A New Twist to the Tale!
Abstracts & commentarySynopsis: The small but significant advantage for omeprazole 20 mg in the H. pylori-positive patients was, perhaps, related to enhanced acid secretion in the presence of H. pylori.
Sources: Blum AL, et al. Gut 2000;47:473-480; McColl KE. Gut 2000;47:461-462.
| Table-Remission Rates at the End of Therapy | |||||
| H. pylori status |
Placebo | Ran 150 mg |
Omep 10 mg |
Omep 20 mg |
|
| + | 42 | 50 | 48 | 59 | |
| - | 66 | 73 | 64 | 71 | |
After a complete diagnostic workup, 792 patients with functional dyspepsia were randomized to two weeks of treatment with either placebo, ranitidine 150 mg, omeprazole 10 mg, or omeprazole 20 mg daily. Therapeutic response was evaluated according to Helicobacter pylori status. Remission rates (%) at the end of therapy were as shown in the Table.
The therapeutic gain for treatment over placebo was significant only for omeprazole 20 mg in H. pylori-positive patients (17.6%). However, omeprazole 20 mg led to a significant rate of complete disappearance of symptoms in all patients. Interestingly, relapse rates among responders were low (< 20%) at follow-up at six months. Blum and associates concluded that the small but significant advantage for omeprazole 20 mg in the H. pylori-positive patients was, perhaps, related to enhanced acid secretion in the presence of H. pylori. Comment by Eamonn M. M. Quigley, MD The role of H. pylori in functional (or nonulcer) dyspepsia remains highly controversial. While no one would dispute the potential benefits of a test-and-treat policy in dyspepsia, in general (also referred to as un-investigated dyspepsia), due to the defined role of this organism in peptic ulcer disease,1 results of H. pylori eradication in functional dyspepsia have been divergent.2 This study addressed another important clinical issue; namely, will H. pylori status influence the response to empiric acid-suppressive therapy in functional dyspepsia? The answer is yes; at least in the short term. While Blum et al did not detect any significant difference in remission rates between placebo and the various acid-suppressive regimes tested in H. pylori-negative patients, a small but significant therapeutic advantage was found for omeprazole 20 mg in H. pylori-positive patients. However, placebo response rates were high (66% in the H. pylori-negative group!) and response rates were lower for all groups in H. pylori-positive patients. Blum et al suggested that H. pylori eradication may render these dyspeptic patients more resistant to acid suppression and concluded that this was yet another argument against H. pylori eradication! However, an accompanying editorial argues,with equal vigor, that the difference in response rate could have resulted from a preponderance of pre-ulcer disease in the H. pylori-positive group; a condition that could have been more effectively and permanently treated by H. pylori eradication. The debate continues.
References
1. Gonzaga Vaz Coelho L, et al. Am J Gastroenterol 2000;95:2688-2691.
2. Danesh J, Pounder RE. Lancet 2000;355:766-767.
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