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Editor,—The paper by Misiewiczet al (Gut1997;41:735–9) is an important contribution which demonstrates the usefulness of lansoprazole and clarithromycin combined with either amoxycillin or metronidazole in the treatment ofHelicobacter pylori infection.
However, there are some questions which arise:
(1) Only half the patients had duodenal ulcers. There is good evidence that the response rate to eradication therapy is inferior in other patients and it is hard to justify grouping ulcer and non-ulcer patients together in the study.
(2) Why use lansoprazole 30 mg twice daily? Optimal acid reduction should be achievable with 30 mg daily, and doubling the dose merely reduces the cost effectiveness of this drug. The balance of evidence suggests that omeprazole 40 mg daily, lansoprazole 30 mg daily and pantoprazole 40 mg daily should be equivalent in these regimens.
(3) It is amazing to read that the combination of lansoprazole or omeprazole with twice daily amoxycillin and metronidazole was judged to be “effective”. The success rates achieved were 66 to 83% depending upon the method of analysis. These sorts of incomplete success rates rightly led to the abandoning of dual therapy with omeprazole and amoxycillin or clarithromycin, and are no better than the old triple therapy with bismuth, tetracycline and metronidazole, which has now been superseded.
If success rates of 90% cannot be achieved there are better treatments available.
Editor,—We thank Dr Bateson for his interesting comments. We should like to reply to each of his questions in turn.
(1) The success of H pylorieradication therapy depends on the patients’ compliance with treatment and the sensitivity of the bacterium to antimicrobials.1-1We are unaware of studies reporting significantly greater efficacy in patients with duodenal ulcer disease, compared with patients with non-ulcer dyspepsia.
(2) When combined with clarithromycin and a nitroimidazole, we agree that at present there seems to be no therapeutic advantage in increasing the dose of lansoprazole above 30 mg,1-2 omeprazole above 20 mg,1-3 or pantoprazole above 40 mg1-4 daily. However, no such comparative data exist for the combination of a proton pump inhibitor (PPI) with clarithromycin and amoxycillin. When we planned the study, the data available supported the twice daily use of a PPI with antimicrobials, and also the patients’ compliance seems to be better.
(3) A PPI together with amoxycillin and metronidazole was “judged to be effective” as this combination produced eradication of H pylori in 88 to 94% of patients with metronidazole sensitive strains, according to intention to treat analysis. In such circumstances, these regimens were as effective as the other treatment arms. However, these regimens are significantly less effective in the presence of metronidazole resistant strains, with eradication between 46 and 62%. As discussed in the paper, these regimens are not recommended where antimicrobial sensitivities ofH pylori are unknown or in areas where the prevalence of such strains is at least 30%, where a PPI in combination with amoxycillin and clarithromycin should be the first choice of treatment.
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