Helicobacter pylori test-and-eradication strategy

Abstract

Authors' reply Sir—The question of generalisability has to be carefully assessed in all clinical trials before they are implemented in clinical practice. Alberto Pilotto and co-workers question whether our results are applicable to dyspeptic patients aged 65 years and older for H pylori test and eradication to identify patients with peptic ulcer, gastric cancer, and oesophagitis. Pilotto and co-workers' findings, however, relate to a selected subsample of dyspeptic patients who had been referred for investigation, and might have no relevance to management in primary care of unselected patients without alarm symptoms or signs. We included patients in primary care who had dyspepsia of a nature and severity that made the physician suggest treatment or investigation of any kind. We included 69 patients who were 65 years or older. The family physicians would have managed 43 (62%) of these patients by referral for endoscopy and would have treated 26 (38%) emprically had they not been referred for the trial. 42 patients were randomised for prompt endoscopy and can serve as a validation group for the H pylori test-and-eradicate strategy. 23 (55%) of 42 were H pylori positive, and eight of these patients had peptic ulcer, four had oesophagitis, one had cancer, and ten had normal endoscopy. Three of the six H pylori-negative patients who had used NSAIDs had peptic ulcer; the remaining three had a normal endoscopy. Four of the six H pylori-negative patients with reflux symptoms had oesophagitis; two had normal endoscopy. Five of the seven H pylori-negative patients without NSAID use or reflux symptoms had normal endoscopy, and two had mild oesophagitis. Thus, all patients with peptic ulcer (11 of 11) would have undergone endoscopy or been treated by eradication therapy, which suggests that the strategy is safe for management of such patients in this age-group. However, as previously stated, we have no power to judge the safety for identification of any gastric-cancer patients. We acknowledge the lack of data on the outcome for elderly patients from other clinical trials. Furthermore we doubt the value of post-trial planned subanalysis. However, based on our findings, we recommend the test-and-eradicate strategy as a safe alternative when endoscopy is not readily available, but only for patients with no alarm symptoms or signs. Helicobacter pylori test-and-eradication strategyAnnmarie Lassen and colleagues (Aug 5, p 455)1 report on the Helicobacter pylori test-and-eradicate strategy to manage dyspeptic patients in primary care. At entry, patients with dyspepsia assigned H pylori testing were investigated by carbon-13-labelled urea breath test and separated into groups of H pylori positive, H pylori negative who had taken non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin in the previous month, H pylori negative not using NSAIDs who had reflux symptoms, and H pylori negative not using NSAIDs and without reflux symptoms. Full-Text PDF