Triple therapy for nonulcer dyspepsia related to H. pylori

Triple therapy for nonulcer dyspepsia related to H. pylori

The concept of eradication of Helicobacter pylori with triple therapy has been controversial in patients who have dyspepsia in the absence of ulcer (as determined by endoscopy). The prevalence of H. pylori infection in patients with nonulcer dyspepsia ranges from 39 to 87 percent, implying that H. pylori infection may account for the symptoms of nonulcer dyspepsia and may play a role in gastritis formation. Sheu and colleagues conducted a one-year study to evaluate the impact of triple therapy on the course of nonulcer dyspepsia.

A total of 41 patients less than 45 years of age who had symptomatic nonulcer dyspepsia were randomly assigned to one of two treatment groups. Patients were confirmed to have H. pylori-related nonulcer dyspepsia by serologic tests, rapid urease tests and antral biopsy. The control group consisted of 21 patients who were treated with a histamine H2 blocker for two months. An H2 blocker or sucralfate was thereafter prescribed on an as-needed basis for one year. The second group consisted of 20 patients who received the triple therapy regimen (colloidal bismuth subcitrate, 120 mg three times per day for four weeks, metronidazole, 500 mg three times per day for two weeks, and amoxicillin, 500 mg three times per day for two weeks). Patients who received the triple therapy regimen then followed the same regimen of antisecretory agents as the control group for the remainder of the year.

The efficacy of the therapy was measured by symptom scores, H. pylori IgG titers as determined by enzyme-linked immunosorbent assay (ELISA), and endoscopy with rapid urease tests and histologic gradings. Symptoms monitored included daytime epigastric pain, night or hunger pain, nausea or vomiting, acid sensation or regurgitation, and nonspecific symptoms. They were scored on a scale of zero to 2. A score of zero represented symptom-free status; a score of 1 represented occasional attacks with partial relief with drug treatment, and a score of 2 represented daily attacks or attacks that were frequent enough to interfere with daily activities.

Based on the results of histologic grading and rapid urease tests, H. pylori eradication was achieved after two months of treatment in 15 of the 20 patients in the triple therapy group and in none of the patients in the control group. Histologic improvement in patients with acute and chronic inflammation was more significant in the triple therapy group than in the control group. Serologic studies were performed at weeks 2 and 4, at months 2 and 6, and at the end of the year. H. pylori IgG titers, especially after week 4, decreased throughout the year in patients in whom H. pylori was eradicated, while titers hardly changed in the control group. With regard to symptomatology, initial mean scores were comparable in both groups and declined after treatment began. Patients who received triple therapy showed greater improvement, however, after two, six and 12 months. In contrast, the mean symptom score in the control group increased again at the end of the year.

The authors determined that H. pylori was eradicated in 75 percent of the patients who received triple therapy. Patients in whom eradication was accomplished had greater symptomatic relief and showed both histologic and serologic improvements. The authors conclude that it is beneficial to begin triple therapy for patients with H. pylori-related nonulcer dyspepsia who have troublesome symptoms. (Sheu BS, et al. Long-term outcome of triple therapy in Helicobacter pylori-related nonulcer dyspepsia: a prospective controlled assessment. Am J Gastroenterol 1996;91:441-6.)

COPYRIGHT 1996 American Academy of Family Physicians

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