Álvaro Nagib Atallah*
Evidence for the treatment of chronic peptic ulcer
or many years surgery was considered an important
approach for the treatment of chronic peptic ulcer.
Thousands of patients were submitted to surgery in
the absence of appropriate controlled trials. If such trials
had been undertaken, the history ofthe disease could have
been different. Once the link between Helicobacter pylori
infection and chronic peptic ulcer had been established,
new treatment guidelines based on scientific evidence were
required.
If the interested
c1inician were to consult the
Cochrane Library, he would find no systematic review
prepared by the Cochrane Collaboration Group, but two
reviews prepared by outside the collaboration.
One of
these, focuses on the effectiveness
and the economic
aspects of treatrnent ', and other on the efficacy of
antibiotictherapy in erradicating Helicobacter pylori. 2 Both
have been assessed by the Cochrane Collaboration.
Basically the studies are supposed to compare placebo with
omeprazole plus amoxicillin, or these two (dual therapy)
with triple therapy
(colloidal
bismuth
subcitrate,
metronidazole
and tetracycline)
ar quadruple therapy
(omeprazole,
colloidal bismuth subcitrate, tetracycline
hyelrochloriele and rnetronidazole).
As can be seen, we have many agents to be compareel
two by two, three by three, four by four, or even to use
thern alI. Obviously, when the number of agents increases,
the chances of aelverse effects and cost increases. Hence
there are many questions that neeel to be answereel by
appropriate research. If we look at the Cochrane Library
elatabase, we finei 157 references on this subject. While it
is gooel news that there is so much information, the question
P
*
MO, PhO, MCE
Chairman, Oepartment of Intemal Medicine, Escola
Paulista de Medicina, Editor, São Paulo Medical Joumal.
ATALLAH. A.N. - Evidence
for the treatment
of chronic peptic ulcer
remain of what to elo in practice? Two recent trials have
been publisheel that may help to aelress this questiono
Boer e col.', in "Quadruple therapy erradicated H.
pylori-associated
peptic ulcer disease better than dual
therapy", compared quadruple therapy (n = 40) with dual
therapy (n = 36). Quaelruple therapy inclueled orneprazole
- 20 mg twice daily on elays I to 10; colloielal bismuth
subcitrate, 120 mg, 4 tirnes/d, on elays 4 to 10; tetracycline
hydrocloride,
500 rng, 4 times/d, on elay 4 to 10; and
metronidazole 500 mg, 3 times/eI, on days 4 to 10. Dual
therapy includeel orneprazole, 20 mg twice daily, on days
1 to 14 anel arnoxicillin, 1000 rnh twice daily, on days I to
14. The studied patients where who had chronic peptic
ulcer disease anel eneloscopically
proved Helicobacter
Pylori infections. The effects were biopsy confirmed.
Quadruple therapy leel to a higher cure rate than elicl
dual therapy 93% vs 56%, P < 0,00 I. The rate of adverse
effects was higher in the group that receivecl quaclruple
therapy than elual therapy group.
Thijs e col.vcompared triple therapy, colloidal bisrnuth
subcitrate, 120 mg, 4 ti mes/eI, metronidazole 250 rng, 4
tirnes/d, and tetracycline 250 mg, 4 times/d, with dual
therapy, omeprazole 40 mg twice elaily anel amoxicillin 1000
mg twice daily. Both regimens were taken for 14 days. Triple
therapy led to a higher rate of cure than dual therapy (95%
vs 70%, P < 0,00 I). Again siele effects were more frequently
associateel with triple than with elual therapy.
Although more larger trials are needed, the reader
can already make a therapeutic decision, keeping in minei
that the fewer elrugs useel increases cornpliance anel reduces
side effects.
Besieles the inforrnation in the Cochrane Library the
reader can also refer to the cornrnentary on the papel' by
Schoenfeld anel Butler 4, anel will have more evielence to
guide his pratice.
São Paulo Medicat
Journat/RPM
115(1): 1327-1328,
1997
1328
REFERENCES
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3.
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WM,
Jansz AR, Tytgat
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for eradication
of
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1995:7: 11X9-9-1.
Chiba N. Rao I3V. Radernaker
JW, I-1Ullt RI-I. Meta-analysis
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-I.
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y
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uf
1:'!:i-
ATALLAH, A.N. - Evidence for lhe Ireatment of chroruc peptic ulcer