Editor—Manes et al reported their trial of Helicobacter pylori test and treat v initial proton pump inhibitors.1 Their results in secondary care are encouraging in that eradication treatment for H pylori reduced the relapse of symptoms by 33% compared with a short course of treatment to suppress acid. However, we doubt whether their findings have any relevance to the use of “test and treat” in primary care.
Manes et al used an aggressive investigative strategy of testing, treating, and endoscopy v proton pump inhibitor and endoscopy in patients with dyspepsia who attended a single hospital clinic. All patients in the trial had intensive monthly then two monthly follow up and underwent endoscopy if symptoms recurred after their initial treatment. This would not be usual practice in primary care, where trials have shown that only 25% of young dyspeptic patients undergo endoscopy within a year after consultation.2
In addition, the prevalence of H pylori was extremely high (61%), whereas the prevalence in most north European countries and North America may be only 20-30% in similar young patients.
Whether an initial strategy of H pylori test and treatment or acid suppression should be used is really an issue of cost effectiveness.3 The CADET-Hp study showed a 14% absolute reduction in dyspeptic symptoms when eradication treatment was compared with proton pump inhibitors and placebo.4 However, it enrolled only patients who were positive for H pylori and cannot therefore compare costs at strategy level, where the costs of testing and managing the H pylori negative patients must be included.4
Competing interests: All authors are currently recruiting patients to a trial of test and treat v proton pump inhibitor from 55 practices in the United Kingdom, funded by the Medical Research Council.
References
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