Are Antibiotics Useful in the Treatment of Peptic Ulcer?

Fifty-five trials involving  peptic ulcer treatment in H. pylori-positive adults were selected for review
Fifty-five trials involving peptic ulcer treatment in H. pylori-positive adults were selected for review

Peptic ulcer disease is a common condition affecting approximately 10% of people in Western countries. About 95% of duodenal ulcers and 70% of gastric ulcers are linked to Helicobacter pylori infection. While H. pylori eradiction therapy, which consists of an acid suppressing drug combined with two antibiotics, may reduce the relapse rate of ulcers, it is unclear whether using antibiotics as part of the combination is helpful compared to no treatment or other treatments. In this updated review, published online in the Cochrane Library, researchers aimed to assess the magnitude of effect H. pylori eradication therapy has on H. pylori-positive patients with peptic ulcer disease.

Fifty-five randomized trials involving both short- and long-term peptic ulcer disease treatment in H. pylori-positive adults were selected for this review. The trials included patients who received at least one week of eradication therapy (eg, proton pump inhibitor [PPI dual therapy [PPI + amoxicillin or clarithromycin]; PPI triple therapy [PPI + two of the following: amoxicillin, macrolide, 5 nitroimidazole]; H2 receptor antagonist [H2RA] triple therapy [H2RA + two of the following:  amoxicillin, macrolide, 5 nitroimidazole]; bismuth triple therapy [bismuth salt + 5 nitroimidazole with either amoxicillin or tetracycline]; bismuth quadruple therapy [as bismuth triple therapy + PPI]; ranitidine bismuth citrate dual/triple therapy [as for PPI]; clarithromycin monotherapy) compared with placebo, no treatment, or ulcer healing drug (PPI, H2RA, bismuth salts, sucralfate, regular antacid, antacid PRN); data collection included ulcer healing, ulcer recurrence, symptom relief, and adverse effects.  

The main objectives of the study included:

  • Proportion of peptic ulcers healed with eradication therapy compared to placebo, other drug therapy
  • Proportion of patients who remained symptom free from relapse with eradication therapy compared to placebo, other drug therapy
  • Proportion of patients who had complete relief of symptoms, improvement in quality of life scores
  • Incidence of adverse effects for the different therapies
  • Proportion of patients who had successful eradication

In the healing of duodenal ulcer, H. pylori eradication therapy showed a larger benefit over no treatment and a small benefit over ulcer-healing drug. However, the opposite was seen in gastric ulcer healing, where the results slightly favored ulcer-healing drug alone. With regards to ulcer recurrence rate, the researchers found there was a significant relative risk reduction of 80% in duodenal ulcer recurrence as well as a significant, albeit smaller, risk reduction of 69% for gastric ulcer recurrence with eradication therapy compared to short-term course of ulcer-healing drug. 

In duodenal ulcer recurrence, one week of eradication therapy appears to be as effective as maintenance treatment with ulcer-healing drug. For both duodenal and gastric ulcer, eradication therapy is effective in preventing recurrence compared to no treatment. As for symptom relief, there was no significant improvement with eradication therapy versus comparison regimen, but the number of studies that reported this outcome was small (no studies evaluated symptoms beyond 6 weeks). 

The incidence of adverse effects (ie, diarrhea, nausea/vomiting, skin rash, epigastric pain, altered taste, stomatitis) appeared to be greater with eradication therapy than with comparison regimen. Overall, the rate of successful eradication of H. pylori across all trials was 68%. 

The authors conclude that "adding a one to two-week course of H. pylori eradication therapy speeds up ulcer healing for people withH. pylori-positive duodenal ulcer when compared to ulcer-healing drugs alone and no treatment," however "there is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer-healing drug." Because the quality of evidence was low, there is uncertainty regarding these results.

For more information visit CochraneLibrary.com.

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