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Abstract & Commentary
Synopsis: Even in physician-diagnosed peptic ulcer disease, test-and-treat strategy for H pylori did not reduce costs, and use of acid-reducing medications remained very high.
Source: Allison JE, et al. Arch Intern Med. 2003;163: 1165-1171.
It has been proposed that peptic ulcer disease (PUD) should lead to treatment for Helicobacter pylori (HP) if present. It has been assumed that such HP eradication would eliminate any requirement for future therapy, thus reducing health care costs. In this study by Allison and colleagues, 650 patients on long-term acid suppression for PUD specifically diagnosed by physicians were randomized to test-and-treat (T&T) for HP or usual care. Mean age was 57, 48% of patients were male, and 63% were non-Hispanic whites. Diagnosis of PUD was either based on endoscopy or x-ray or on a typical ulcer history (eg, epigastric pain relieved by food, antacids, H2 receptor antagonists, or PPIs). GERD in the absence of PUD was specifically excluded as was chronic NSAID use. A total of 321 patients were randomized to T&T, and the other 329 were continued on usual management. Only 17% of all study participants had PUD documented by endoscopy or radiography. Only 38% of all patients had a positive test for HP. Although ulcer-like dyspepsia and use of acid-reducing medications were less likely to be present after 12 months in the T&T subset, 75% of the T&T group continued to use acid blockers. Overall costs were higher in the T&T group than in those receiving usual care, mostly attributable to urea breath testing and to the HP treatment. HP was successfully eradicated in 84% of those found to be positive as analyzed per protocol.
Comment by Malcolm Robinson MD, FACP, FACG
Physician diagnosis of PUD seems to be woefully inadequate, and most patients thought to have this diagnosis prove to have nonulcer dyspepsia. It is clear that HP eradication does not benefit nonulcer dyspepsia. Even in the HP-positive group that was successfully eradicated, 41% still had dyspepsia at the 12-month follow-up. Most patients diagnosed with PUD in this large managed care setting had neither PUD nor HP. Possibly unlike other geographic settings, there seems to be little benefit in the T&T strategy in the United States.
It is possible that results would have been different if only patients with documented PUD were included. However, the increasing incidence of PUD in the absence of HP suggests that even this group might not benefit from HP testing. Nevertheless, most authorities still agree that HP eradication is appropriate with documented infection in the presence of unequivocal gastric or duodenal ulcer or malt lymphoma of the stomach.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.