Meta-analysis: Sequential Therapy Appears Superior to Standard Therapy for Helicobacter pylori Infection in Patients Naive to Treatment

17 June 2008 | Volume 148 Issue 12 | Pages 923-931

Background: Standard proton-pump inhibitor–based therapy for Helicobacter pylori infection fails in up to one quarter of patients. Sequential therapy may be more efficacious.

Purpose: To compare sequential therapy with standard triple therapy for H. pylori infection.

Data Sources: MEDLINE, EMBASE (1981 to October 2007), the Cochrane Central Register of Controlled Trials, and Google Scholar. PubMed and Ovid were the search engines used.

Study Selection: Randomized, controlled trials (RCTs) comparing sequential and standard triple therapies in treatment-naive patients with documented H. pylori infection.

Data Extraction: 3 reviewers independently assessed trial eligibility and quality and extracted data on eradication.

Data Synthesis: The crude rates of H. pylori eradication in 10 RCTs involving 2747 patients were 93.4% (95% CI, 91.3% to 95.5%) for sequential therapy (n = 1363) and 76.9% (CI, 71.0% to 82.8%) for standard triple therapy (n = 1384) (relative risk reduction, 71% [CI, 64% to 77%]; absolute risk reduction, 16 percentage points [CI, 14 to 19 percentage points]). The median rates of adherence were 97.4% (range, 90.0% to 98.9%) for sequential therapy and 96.8% (range, 93.0% to 100%) for standard therapy. Sequential therapy appeared superior in prespecified sensitivity (subgroup) analyses stratified by trial quality; smoking status; diagnosis (ulcer disease or nonulcer dyspepsia); resistance to clarithromycin, imidazoles, or both; duration of triple therapy; and method of diagnosis. Both treatments had similar side effect profiles.

Limitations: Only 1 study was double-blinded. Most patients were from Italy. There was clear evidence of publication bias.

Conclusion: Sequential therapy appears superior to standard triple therapy for eradication of H. pylori infection. If RCTs in other countries confirm these findings, 10-day sequential therapy could become a standard treatment for H. pylori infection in treatment-naive patients.

Editors' Notes Context Efficacy of treatment for Helicobacter pylori infection is declining, possibly because of antibiotic resistance. Sequential provision of antibiotics may help overcome that resistance. Contribution In this review and meta-analysis of 10 trials, the investigators found evidence consistently favoring sequential over standard triple therapy for H. pylori infection. Caution Most trials were performed in Italy, 1 was performed in children only, and the investigators found strong evidence of publication bias. Implication Sequential therapy seems superior to standard therapy for treatment of H. pylori infection. —The Editors

 

Author and Article Information

From University of Louisville, Louisville, Kentucky, and Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Potential Financial Conflicts of Interest: Consultancies: C.W. Howden (Meretek, TAP, Takeda, Santarus, Novartis); Honoraria: C.W. Howden (AstraZeneca, Meretek, Santarus); Grants received: C.W. Howden (AstraZeneca).

Requests for Single Reprints: Colin W. Howden, MD, Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611; e-mail, c-howden{at}northwestern.edu.

Current Author Addresses: Dr. Jafri: University of Louisville, 550 South Jackson Street, ACB 3rd Floor, Louisville, KY 40202.

Dr. Hornung: University of Louisville School of Public Heath and Information Sciences, 4063 K Building, 555 South Floyd Street, Louisville, KY 40202.

Dr. Howden: Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611.

Read all Rapid Responses

Sequential Treatment for Helicobacter pylori infection

Luigi Gatta, et al.

Annals Online, 7 Jul 2008 [Full text]

Reply to Dr. Gatta and colleagues

Colin W Howden, et al.

Annals Online, 21 Jul 2008 [Full text]