Editor—Finding that patients with dyspepsia gain modest benefits from eradication of Helicobacter pylori, Moayyedi et al conclude that this intervention “may be cost effective.”1 This conclusion should be taken with quite a bit of healthy scepticism. They say that one patient benefiting out of 15 treated with antibiotics may represent good value for money, depending on decision makers' willingness to pay for relief of dyspepsia. However, the risks associated with the antibiotic treatment are not taken into account in the economic model used.
The table summarises the results of two of the included trials,2,3 showing an absolute increase in withdrawal from the trial due to adverse events. Number needed to harm values are very close to the number needed to treat found by Moayyedi et al, meaning that of each 15 patients treated one could benefit but another one could experience side effects leading to withdrawal from the trial. Moreover, a message to test and eradicate H pylori in all patients with non-ulcer dyspepsia could lead to a long term risk of antibiotic resistance.
Additionally, dyspepsia was “forced” into a dichotomous outcome. There may be different degrees of upper abdominal pain or discomfort, so considering dyspepsia only as “present” or “absent” oversimplifies the picture. In specifying a number needed to treat of 15, the authors cannot say what improvement is gained by patients who responded to treatment. If 15 patients are treated and one of them benefits, how different is this one from the other 14? Data on quality of life included in the review seem to show that there are no differences between the eradication and control groups.
The studies included in this meta-analysis use quite different scales to measure dyspepsia. In the Glasgow scale, scores of 0-1 out of 21 represent a favourable outcome4; in some Likert scales, scores of 0-1 out of 4 to 7 points represent the same outcome.2,3 The discriminative power of these scales is obviously very different, and combining results derived from using such scales may be problematic.
Eradicating H pylori does not seem to decrease the long term use of acid suppressive treatment. More than 50% of patients with non-ulcer dyspepsia still take such treatment five years after the successful eradication.5
Finally, most of the studies included in this meta-analysis come from secondary care. It may be difficult to generalise these results to primary care patients who may differ in terms of adherence to treatment and severity of symptoms.
Table.
Withdrawals owing to side effects and numbers needed to harm in two trials of Helicobacter pylori eradication (follow up of one year)
| Study | Withdrawal owing to side effects (%)
|
Increase in absolute risk | No needed to harm | |
|---|---|---|---|---|
| Eradication group | Control group | |||
| Blum et al2 | 7 | 1 (omeprazole) | 6.0 | 17 |
| Talley et al3 | 4 | 0 (placebo) | 4.0 | 25 |
There were 348 participants in the Blum et al study and 170 in the Talley et al study.
References
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