Bismuth salicylate for diarrhea in children

QUESTION

Recently, I had a visit from a 5-year-old patient who had been given bismuth subsalicylate for a diarrheal illness by a local family physician during a trip to South America. Is this a practice we should encourage?

ANSWER

Research from developing countries has found the use of bismuth subsalicylate to be effective in shortening the duration of diarrheal illness. Despite these findings, its limited effectiveness and concerns about it potentially causing Reye syndrome, compliance, and cost are the key reasons it is not routinely recommended for children.

Comparative chemical study of MTA and portland cements

Portland cement has been analyzed and compared to mineral trioxide aggregate (MTA) because of their chemical similarity. The possibility of using this material as a less expensive alternative to MTA in dental practice should be considered. In view of this, the present study compared the components of a Portland cement (Votoran®) to two commercial brands of MTA (Pro-Root™ and MTA-Angelus®). Twelve specimens of each material were fabricated and examined by scanning electron microscopy (SEM) with energy dispersive spectroscopy (EDS) to obtain their percentage of chemical elements. The means of the chemical elements found in each material was compared by descriptive statistics. Bismuth was present only in MTA cements to provide radiopacity. In conclusion, the tested cements have similar components, which supports, as far as composition is concerned, the possible clinical use of Portland as an option to MTA.

Impact of Helicobacter pylori eradication on dyspepsia, health resource use, and quality of life in the Bristol helicobacter project: randomised controlled trial

OBJECTIVE

To determine the impact of a community based Helicobacter pylori screening and eradication programme on the incidence of dyspepsia, resource use, and quality of life, including a cost consequences analysis.

DESIGN

H pylori screening programme followed by randomised placebo controlled trial of eradication.

SETTING

Seven general practices in southwest England.

PARTICIPANTS

10,537 unselected people aged 20-59 years were screened for H pylori infection (13C urea breath test); 1558 of the 1636 participants who tested positive were randomised to H pylori eradication treatment or placebo, and 1539 (99%) were followed up for two years.

INTERVENTION

Ranitidine bismuth citrate 400 mg and clarithromycin 500 mg twice daily for two weeks or placebo.

MAIN OUTCOME MEASURES

Primary care consultation rates for dyspepsia (defined as epigastric pain) two years after randomisation, with secondary outcomes of dyspepsia symptoms, resource use, NHS costs, and quality of life.

RESULTS

In the eradication group, 35% fewer participants consulted for dyspepsia over two years compared with the placebo group (55/787 v 78/771; odds ratio 0.65, 95% confidence interval 0.46 to 0.94; P = 0.021; number needed to treat 30) and 29% fewer participants had regular symptoms (odds ratio 0.71, 0.56 to 0.90; P = 0.05). NHS costs were 84.70 pounds sterling (74.90 pounds sterling to 93.91 pounds sterling) greater per participant in the eradication group over two years, of which 83.40 pounds sterling (146 dollars; 121 euro) was the cost of eradication treatment. No difference in quality of life existed between the two groups.

CONCLUSIONS

Community screening and eradication of H pylori is feasible in the general population and led to significant reductions in the number of people who consulted for dyspepsia and had symptoms two years after treatment. These benefits have to be balanced against the costs of eradication treatment, so a targeted eradication strategy in dyspeptic patients may be preferable.

How to treat Helicobacter pylori. First-line, second-line, and future therapies

Numerous trials were performed in the 1990s to define the optimal therapy for Helicobacter pylori infections. The proposed proton-pump inhibitor (PPI)-based and ranitidine bismuth citrate (RBC)-based triple therapies led to satisfactory results. Their first drawback is cost, and, for this reason, many people worldwide cannot benefit from these regimens. Failures of first-line therapies essentially are because of antimicrobial resistance, which increases with the selection pressure resulting from the use of these drugs. Second-line treatments using antimicrobial agents for which H. pylori resistance is low or nonexistent are being tested to find alternatives to the quadruple therapy. There is a need for new drugs, which should be highly effective, nonselective of resistant strains, and without side effects, to improve current regimens. These drugs may be the results of postgenomic studies.

Helicobacter pylori-positive duodenal ulcer: three-day antibiotic eradication regimen

BACKGROUND

The most widely used treatments for ulcer healing and Helicobacter pylori eradication consist of a 1-2 week regimen of a proton pump inhibitor plus two or three antimicrobials.

AIMS

To evaluate the efficacy, safety, cost, and tolerance of a three-day regimen with three antibiotics vs. a 10-day treatment with a proton pump inhibitor or vs. a ranitidine bismuth citrate triple therapy.

METHODS

Two hundred and twenty-one patients with endoscopically-proven H. pylori-positive duodenal ulcers were recruited to the study. Recruited patients were assigned to one of the following four regimens: (I) omeprazole 40 mg o.m. plus amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. for 10 days (OAC: 55 patients); (ii) omeprazole 40 mg o.m. on days 1-5, plus amoxycillin 1 g b.d., clarithromycin 500 mg b.d. and metronidazole 500 mg b.d. on days 3-5 (OACM: 56 patients); (iii) ranitidine bismuth citrate 400 mg b.d. plus amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. for 10 days (RAC: 54 patients); (iv) ranitidine bismuth citrate 400 mg b.d. on days 1-5, plus amoxycillin 1 g b.d., clarithromycin 500 mg b.d. and metronidazole 500 mg b.d. on days 3-5 (RACM: 56 patients). Fisher's exact test was used to compare data regarding healing and eradication in the four groups.

RESULTS

The intention-to-treat eradication and ulcer healing rates for the RACM regimen were 95% and 98%, respectively. Statistically significant differences were observed, relating to the eradication and healing of ulcers, between RACM and either the RAC or OAC regimens.

CONCLUSION

The three-day antibiotic therapy with amoxycillin, clarithromycin and metronidazole in addition to ranitidine bismuth citrate is a very effective anti-H. pylori regimen.

Helicobacter pylori eradication in clinical practice: retreatment rates and costs of competing regimens

OBJECTIVE

To measure outcomes for eradication regimens for Helicobacter pylori infection in routine clinical practice.

DESIGN

Retrospective analysis of an integrated medical and pharmacy claims database identified patients treated from June 1, 1995 through May 31, 1996, and followed the patients' claims until December 31, 1996.

SETTING

The database represented multiple health plans throughout the US.

PATIENTS

Patients were > or = 16 years old, continuously enrolled from April 1, 1995, to December 31, 1996, and met clinical (diagnostic or procedural) criteria.

INTERVENTION

Patient cohorts were treated with bismuth-based triple (n = 98), proton-pump inhibitor (PPI)-based triple (n = 180), or PPI-based dual (n = 337) regimens.

OUTCOME MEASURES

Retreatment; monthly postregimen medical expense, controlling for preregimen expense; and drug cost per successfully treated patient. Cox regression (retreatment analysis) and ANCOVA (postregimen expense analysis) adjusted for age, gender, diagnostic/procedural criteria met by patient, and specialty physician use.

RESULTS

Retreatment rates were higher (p < 0.05) for PPI-based dual than bismuth-based or PPI-based triple-therapy cohorts. Retreatment rates for bismuth- and PPI-based triple-therapy cohorts were not significantly different. Total and follow-up (excluding the first 2 wk of treatment) expenses were higher for retreated than nonretreated patients (p < 0.01). Total expenses were higher for the PPI-dual cohort (p < 0.05) than for triple cohorts. Drug costs per successfully treated patient were $30 for bismuth-based, $172 for PPI-based triple, and $208 for PPI-based dual-therapy regimens.

CONCLUSIONS

PPI-based dual-therapy regimens are not cost-effective in H. pylori treatment. Further study should compare more costly (PPI-based) versus less costly (bismuth-based) triple-therapy regimens.

The pharmacoeconomic impact of antimicrobial therapy for peptic ulcer disease in a large urban jail

PURPOSE

To determine the pharmacoeconomic impact of antimicrobial treatment of peptic ulcer disease (PUD) in a large urban jail.

PATIENTS AND METHODS

Retrospective comparison of PUD-related pharmacy and laboratory expenditures over a 2-year period before and after the institution of a PUD treatment protocol with the priority of Helicobacter pylori eradication for inmates in Rikers Island Correctional Facility.

RESULTS

After the protocol was adopted, total pharmacy-related and laboratory-related expenses for PUD care decreased by 40.2%, and expenditures for ranitidine declined by 52.2%. There was an increase in spending for antimicrobial agents and H. pylori antibody testing, but this was insignificant compared to the savings generated by decreased ranitidine usage. Annual savings in our facility as a result of this intervention were $123,449.

CONCLUSIONS

Modern therapeutic strategies for PUD aimed at eradicating H. pylori can result in significant savings in the institutional setting; these savings are largely attributable to the decreased usage of histamine-2 receptor antagonists.