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Las Vegas,
NV— Depending upon the prevalence of H pylori in a given
demographic area, empiric antisecretory therapy offers a modest,
cost-effective alternative to “test and treat” for the
management of uninvestigated dyspepsia, William D. Chey, MD, Associate
Professor, Department of Internal Medicine, University of Michigan,
Ann Arbor, said.
“Where H pylori prevalence is less than 20 per cent, empiric
antisecretory therapy is always less costly than test and treat,”
Dr. Chey said. “If test and treat can be shown to have important
downstream clinical benefits, i.e. improving patients with nonulcer
dyspepsia or preventing gastrointestinal carcinoma, that will of
course shift this equation.”
The finding is significant in light of the U.S. trend toward declining
H pylori prevalence, peptic ulcer disease prevalence, and the fraction
of ulcers attributable to H pylori infection, he added.
Decision analysis
Dr. Chey and colleagues used a symptom-driven decision analytic
model to evaluate both treatment strat-egies in an environment where
H pylori prevalence is falling and the likelihood of H pylori-negative
ulcers is rising.
The virtual cohort included 1,000 patients who had uncomplicated
dyspepsia with no history of H pylori infection or peptic ulcer
disease. Patients were managed with the test and treat strategy
(14 days of PPI-based triple therapy for ELISA-positive patients;
four weeks of PPI for ELISA-negative patients) or the empiric antisecretory
treatment (four weeks of PPI). Nonresponders underwent upper endoscopy
and received therapy for treatment failures or symptom recurrence.
The following assumptions were made:
• No benefit of H pylori therapy in patients with non-ulcer
dyspepsia
• H pylori prevalence: 25 per cent
• Peptic ulcer disease prevalence: 20 per cent
• Ulcers attributable to H pylori infection: 75 per cent
• Clinical outcomes for both treatment strategies: equivalent
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