Helicobacter pylori test-and-treat' strategy for dyspeptic patients

Helicobacter pylori "Test-and-Treat" strategy with urea breath test: A cost-effective strategy for the management of dyspepsia and the prevention of ulcer and gastric cancer in Spain-Results of the Hp-Breath initiative

BACKGROUND

Data from clinical trials comparing Helicobacter pylori (H. pylori) management strategies in patients with dyspepsia are limited. Cost-effectiveness simulation models might help to identify the optimal strategy.

OBJECTIVE

To assess the cost-effectiveness of the H. pylori "Test and Treat" (T&T) strategy including the use of urea breath test (UBT) vs symptomatic treatment (ST) and vs upper gastrointestinal endoscopy (UGE) as a first procedure in patients with dyspepsia.

METHODS

Three main strategies: "T&T" strategy including the use of UBT, "UGE" and "ST" have been compared using cost-effectiveness models developed in accordance with the Spanish medical practice. For the model simulations, a time horizon of 4 weeks was considered for the endpoint "Dyspepsia symptoms relief" and 10 years when using "Peptic ulcer avoided" and "Gastric cancer avoided" endpoints.

RESULTS

For the endpoint "Dyspepsia symptoms relief", T&T strategy appears to be the most cost-effective (883€/success) compared to UGE strategy and to ST strategy (respectively 1628€ and 990€/success). For the endpoint "Probability of peptic ulcer", the T&T strategy appears to be the most cost-effective (421€/peptic ulcer avoided/y) compared to UGE strategy and ST strategy (respectively 728€ and 632€/peptic ulcer avoided/y). For the endpoint "Gastric cancer avoided", the T&T strategy appears to be the most cost-effective (524€/gastric cancer avoided/y) compared to UGE strategy and "ST" strategy (respectively 716€ and 696€/gastric cancer avoided/y).

CONCLUSIONS

T&T strategy including the use of UBT is the most cost-effective medical approach for management of dyspepsia and for the prevention of ulcer and gastric cancer.

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

Review article: Helicobacter pylori-negative duodenal ulcer disease

BACKGROUND

Helicobacter pylori infection rates in duodenal ulcer (DU) patients may be lower than previously estimated.

AIM

To review the real prevalence of H. pylori-negative DUs and its possible causes.

METHODS

Bibliographical searches in MEDLINE looking for the terms 'H. pylori' and 'duodenal ulcer'.

RESULTS

Mean prevalence of H. pylori infection in DU disease, calculated from studies published during the last 10 years including a total of 16 080 patients, was 81%, and this figure was lower (77%) when only the last 5 years were considered. Associations with H. pylori-negative DU were: (1) False negative results of diagnostic methods, (2) NSAID use (21% in studies with <90% infection rate), (3) Complicated DU (bleeding, obstruction, perforation), (4) Smoking, (5) Isolated H. pylori duodenal colonization, (6) Older age, (7) Gastric hypersecretion, (8) Diseases of the duodenal mucosa, (9) Helicobacter'heilmanii' infection and (10) Concomitant diseases.

CONCLUSION

In patients with H. pylori-negative DU disease, one should carefully confirm that the assessment of H. pylori status is reliable. In truly H. pylori-negative patients, the most common single cause of DU is, by far, the use of NSAIDs. Ulcers not associated with H. pylori, NSAIDs or other obvious causes should, for the present, be viewed as 'idiopathic'. True idiopathic DU disease only exceptionally exists.

[Seven or ten days? Cost-effectiveness study on the duration of H. pylori treatment in primary care]

OBJECTIVE

To determine through an economic evaluation study whether it is cost-effective to extend treatment of dyspeptic patients from 7 to 10 days, distinguishing between functional dyspepsia, unexamined dyspepsia, and ulcer disease.

DESIGN

Cost-effectiveness study by means of a decision 3 comparing direct costs per patient cured with 2 strategies: a) 7 days treatment versus b) 10 days. Two-year study in the National Health System.

SETTING

Primary care.

PARTICIPANTS

One-hundred patients with peptic ulcer, functional dyspepsia, or unexamined dyspepsia who received treatment for H pylori infection.

INTERVENTIONS

H pylori eradication treatment with a proton pump inhibitor, clarithromycin, and amoxycillin for 7 or 10 days. Measurement variable: incremental cost per patient cured.

RESULTS

In peptic ulcer patients, the incremental cost per patient cured on extending the eradication treatment from 7 to 10 days was euro147 (95% CI, 121.3-162.7), whereas in patients with functional or unexamined dyspepsia, it was -euro39.8 (95% CI, -28.5 to -60.7) and -euro27.3 (95% CI, -14.92 to -52.72), respectively. The sensitivity analysis showed that the efficacy of eradication treatment (7 vs 10) was the factor that most affected the stability of the results.

CONCLUSIONS

Seven days is the most cost-effective duration of the triple therapy for eradicating H pylori in ulcer patients. However, 10 days is more cost-effective in functional dyspepsia patients or those with no prior endoscope diagnosis.

Review article: 13C-urea breath test in the diagnosis of Helicobacter pylori infection -- a critical review

The urea breath test is a non-invasive, simple and safe test which provides excellent accuracy both for the initial diagnosis of Helicobacter pylori infection and for the confirmation of its eradication after treatment. Some studies have found no differences between urea breath test performed under non-fasting conditions. The simplicity, good tolerance and economy of the citric acid test meal probably make its systematic use advisable. The urea breath test protocol may be performed with relatively low doses (<100 mg) of urea: 75 mg or even 50 mg seem to be sufficient. With the most widely used protocol (with citric acid and 75 mg of urea), excellent accuracy is obtained when breath samples are collected as early as 10-15 min after urea ingestion. A unique and generally proposed cut-off level is not possible because it has to be adapted to different factors, such as the test meal, the dose and type of urea, or the pre-/post-treatment setting. Fortunately, because positive and negative urea breath test results tend to cluster outside of the range between 2 and 5 per thousand, a change in cut-off value within this range would be expected to have little effect on clinical accuracy of the test.

Does the 'test-and-treat' strategy work in primary health care for management of uninvestigated dyspepsia? A prospective two-year follow-up study of 1552 patients

BACKGROUND

Although the 'test-and-treat' strategy is suggested as first-line therapy for uninvestigated dyspepsia, no large-scale studies in a real-life setting are available.

METHODS

1552 dyspeptic patients aged between 25 and 60 with no alarm symptoms were recruited to the study. After screening with a 13C-urea breath test, they were randomized into three treatment arms: Helicobacter pylori-positive either to eradication therapy with OAM (omeprazole, amoxycillin and metronidazole) (Hp+/erad) or omeprazole 20 mg daily (Hp+/ome) for 10 days, whereas H. pylori-negative patients (Hp-/ome) were treated with 20 mg omeprazole for 10 days. Gastrointestinal symptoms were registered at baseline at 1 and 2 years on the Gastrointestinal Symptom Rating Scale (GSRS) and quality of life with the Psychological General Well-Being index (PGWB). Additional visits, referrals for and number of endoscopies and their findings were registered during the 2 years' follow-up.

RESULTS

Of the 1552 patients, 583 were H. pylori-positive (37.6%), and 288 of these were randomized for omeprazole and 295 to OAM. The Hp-/ome group had fewer general practitioner (GP) contacts (P<0.0001) than the H. pylori-positive groups. Eradication therapy significantly improved general well-being and reduced upper gastrointestinal symptoms: abdominal pain (P=0.0001), heartburn (P=0.0061), acid regurgitation (P=0.003), hunger pain (P=0.009), especially in Hp+/erad. Peptic ulcer was found in 6.2%, 1.0%, 0.2% in Hp+/ome, Hp-+/erad and Hp-/ome, respectively (P=0.0007). Only 3 patients (1.0%) developed peptic ulcers in Hp-+/erad, all eradication failures.

CONCLUSIONS

In uninvestigated dyspepsia, a negative test result for H. pylori reduces the number of GP contacts and endoscopy referrals compared to H. pylori-positive regardless of eradication therapy. Applied in real life, the test-and-treat strategy failed to reduce the number of endoscopies, but significantly reduced peptic ulcer disease and improved dyspeptic symptoms and quality of life.

The TETRA study: a prospective evaluation of Helicobacter pylori 'test-and-treat' strategy on 736 patients in clinical practice

AIMS

To prospectively evaluate the effectiveness of the test-and-treat strategy in a large group of dyspeptic patients in clinical practice.

METHODS

Patients with ulcer-like dyspepsia, < 45 years, without alarm symptoms, were prospectively studied. Helicobacter pylori infection was diagnosed with the 13C-urea-breath-test, and eradication or symptomatic treatment was prescribed accordingly. 'Symptomatic improvement' was defined as the percentage of patients with a decrease of > or = 2 levels in the dyspepsia-severity-score or with no symptoms after treatment. Health status and use of health resources were also assessed. Endoscopy was performed in therapeutic failures.

RESULTS

Out of 736 patients initially included, 422 received eradication, and 314 symptomatic therapy; 87% returned at 6 weeks and 67% at 6 months. At 6 months, 'symptomatic improvement' was achieved in 73% and 54% of the patients, in eradication and symptomatic groups, respectively (p < .001), and overall in 66%. A reduction of 78% in mean self-assessment visual analogical score was observed at 6 months. More than 50% of patients were 'much better' at control visits. Endoscopy (18%) and physician's visits (13%) were the main health resources used. No gastric or oesophageal cancer was diagnosed.

CONCLUSION

This large prospective study shows that the test-and-treat strategy is effective and safe for management of dyspeptic patients in clinical practice.

[Helicobacter pylori infection and functional dyspepsia. Meta-analysis of efficacy of eradication therapy]

BACKGROUND

To establish a causal link between Helicobacter pylori infection and functional dyspepsia it is necessary to demonstrate that H. pylori eradication induces an improvement in dyspeptic symptoms. Our aim was to perform a meta-analysis of randomized studies comparing, in functional dyspepsia, the efficacy of H. pylori eradication treatment with that of treatments with no effect on H. pylori infection.

PATIENTS AND METHODS

DATA SOURCES

PubMed database, Cochrane Controlled Trials Register, and abstracts from congresses until 2001.

SELECTION CRITERIA

a) studies including patients with functional dyspepsia and H. pylori infection; b) randomized trials comparing H. pylori eradication treatment with treatment (control) with no effect on H. pylori infection, and c) follow-up of at least 6 months. The quality of studies was assessed by a validated score.

STATISTICS

the main outcome was the percentage of patients improving in each therapeutic group. A meta-analysis was performed combining the odds ratios (OR) of individual studies in a global OR.

RESULTS

Nine studies fulfilled the inclusion criteria and were thus included in the meta-analysis. Overall, 953 patients received an eradication treatment and 958 received a control treatment. The overall percentage of patients with symptomatic improvement in the eradication group was 43% (95% CI, 40-46%), and it was 39% (95% CI, 36-42%) in the control group. The OR for the effect of the eradication treatment vs. the control treatment was 1.20 (95% CI, 0.91-1.58). The number needed to treat (NNT) with eradication therapy to achieve a symptomatic improvement, compared with the control group, was 25. Although heterogeneity was demonstrated, it disappeared when one study showing positive, clearly discordant results was excluded. Thus, the percentage of patients with symptomatic improvement in the eradication treatment group was 47% (95% CI, 43-50%) and it was 45% (95% CI, 41-48%) in the control group (OR: 1.06; 0.85-1.31; NNT: 50).

CONCLUSIONS

H. pylori eradication treatment is not associated with a statistically significant improvement of symptoms in patients with functional dyspepsia.

A test-and-treat policy does not save endoscopy workload in a non-referral hospital

AIM

To assess the impact that a test-and-treat policy with open-access urea breath testing (UBT) has had on the referral rates for endoscopy in a district hospital. Additionally, we examined for any change in the proportion of serious pathology detected endoscopically after adopting the policy.

METHODS

Analysis of data on all open-access endoscopy referrals in a 12-month period before (October 1994 to September 1995) and 2 years after (October 1997 to September 1998) the introduction of the UBT service. This was compared with the same service in our sister hospital, which had not provided a UBT service. Results of patients attending the UBT service during the period of study were also examined.

RESULTS

A total of 798 patients attended for endoscopy (18% aged < 40 years, 82% aged > 40 years) in the pre-UBT year compared with 1905 patients (16% aged < 40 years, 84% aged > 40 years) in the post-UBT year. The standardized referral ratios were significantly higher for both age groups in the post-UBT year: 210 in the < 40 years group (95% CI 187 to 235) and 244 in the > 40 years group (95% CI 233 to 257). Six per cent of the < 40 years group in the post-UBT year had serious pathology compared with 7% pre-UBT (P < 0.1). However, the proportion of serious pathology decreased from 37 to 27% in the > 40 years group (P < 0.01). The total number of open-access endoscopies had increased steadily over the 3 years, despite the introduction of the UBT service. This trend was mirrored in our sister hospital. A total of 457 patients attended the UBT service during the 12 months. Of these, 24.5% were Helicobacter pylori positive, with a 66.3% eradication rate.

CONCLUSIONS

A test-and-treat policy has not saved endoscopy workload in this non-referral hospital. We feel that results from centres with an H. pylori interest cannot be generalized for the vast majority.

[Study of the validity of "rapid" serology in diagnosing Helicobacter pylori infection]

OBJECTIVE

To evaluate prospectively the validity of a <<rapid>> serology diagnosis method (using capillary blood) in our ambit, taking for reference a combination of standard diagnostic methods.

DESIGN

Prospective. The endoscopist, pathologist and those responsible for interpreting the rapid urease test, the breath test and <<rapid>> serology did not know the results of the other diagnostic methods.

SETTING

Gastro-enterology service of a tertiary hospital.Participants. 30 consecutive patients with symptoms attributable to the upper digestive tract and who underwent an oral gastroscopy. Main measurements. Gastric biopsies for histology examination and for the rapid urease test and a breath test with 13C-urea were conducted. For <<rapid>> serology, the commercial SureStep HP WB test kit was used. A patient was considered infected when at least two of the three validated techniques (rapid urease test, histology, breath test) were positive; and not infected, when all three were negative.

RESULTS

30 patients, 30% male, with a mean age of 51, were included. The reference standard indicated 61% prevalence of infection, with two cases classed as undetermined. <<Rapid>> serology was positive in 8 patients and negative in 22. Sensitivity, specificity, positive predictive value and negative predictive value were, respectively, 41% (95% CI, 18-65), 91% (74-100), 87% (65-100) and 50% (28-72). The positive probability quotient was 4.5; and the negative, 0.65.

CONCLUSION

The <<rapid>> serology used in the current study has deficient diagnostic accuracy. Therefore, it should not be used in clinical practice to identify H. pylori infection.

[Antibodies against Helicobacter pylori in saliva. Study of their validity versus breath test and its agreement with serology]

OBJECTIVES

To evaluate prospectively the validity of a new diagnostic method based on a saliva sample, taking as reference the breath test with 13C-marked urea, and to compare the results of this technique with another indirect method based on the detection of antibodies, "classical" serology using venous blood.

METHODS

48 individuals, 24 healthy volunteers and 24 consecutive patients with gastro-duodenal ulcer disease, were studied prospectively. Treatment during the previous month with gastro-erosive medication, antibiotics, proton-pump inhibitors or bismuth-derived drugs, prior treatment to eradicate H. pylori, gastric surgery and the presence of linked illnesses, were all considered criteria of exclusion from the study. For the diagnostic test in saliva a commercial enzyme-linked immunosorbent assay (ELISA, trademark Helisal) was used; and for blood serology, another commercial ELISA (Helico-G). The staff responsible for reading the saliva, serology and breath tests did not know the result of the other diagnostic methods. The result of the breath test with 13C-urea (TAU-kit) was taken as the reference standard for H. pylori infection.

RESULTS

The mean age of the healthy volunteers was 23 +/- 0.7 years; and of ulcer patients, 55 +/- 18. The prevalence of H. pylori infection, valued by the gold standard, was 79.2% in the ulcer patients and 54% in the volunteers. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the saliva test in the ulcer patients were, respectively: 100% (95% CI, 79-99), 60% (17-93), 90% (68-98), 100% (31-97) and 92% (71-98). In the volunteers these figures were: 46% (20-74), 73% (39-93), 67% (31-91), 53% (27-78) and 58% (37-77). The serology results were better, with 100% sensitivity in both groups and outstanding diagnostic accuracy (92% and 96% for ulcer patients and volunteers, respectively). Concordance between serology and the saliva test in ulcer patients was perfect (kappa, 1). However, in asymptomatic individuals concordance was deficient (kappa, 0.28), and the prevalence of infection diagnosed with the two tests was not homogeneous (McNemar, 2.8; p < 0.05).

CONCLUSION

The diagnostic test for H. pylori infection in saliva is lacking in diagnostic accuracy in healthy individuals, which indicates that it cannot be used for screening infection in the asymptomatic population. The technique is more valuable in ulcer patients, although it does not reach the specificity desirable. For these reasons, the saliva test evaluated in this study cannot be recommended for diagnosis of H. pylori infection.