Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

Early eradication of Helicobacter pylori is cost-effective

ACP J Club. 1996 Mar-April;124:53. doi:10.7326/ACPJC-1996-124-2-053


Source Citation

O'Brien B, Goeree R, Mohamed AH, Hunt R. Cost-effectiveness of Helicobacter pylori eradication for the long-term management of duodenal ulcer in Canada. Arch Intern Med. 1995 Oct 9;155:1958-64. [PubMed ID: 7575049]


Abstract

Objective

To compare the cost-effectiveness of immediate eradication of Helicobacter pylori, eradication at first ulcer recurrence, and maintenance therapy without eradication for the long-term management of adults with duodenal ulcer.

Design

Decision-analysis model using data from meta-analyses of randomized controlled trials of alternative pharmacologic strategies for treating duodenal ulcers.

Data Sources

Randomized, double-blind, controlled trials that compared therapies for duodenal ulcers and measured recurrences at 6 and 12 months.

Patients

Patients in the model were assumed to have endoscopically proven, uncomplicated duodenal ulcers. Tests for H. pylori were not done.

Intervention

3 strategies were considered: healing with immediate eradication of H. pylori with omeprazole and amoxicillin or with triple therapy (ranitidine followed by bismuth subsalicylate, metronidazole, and tetracycline or amoxicillin); ranitidine for healing then waiting for recurrences (recurrences were treated with ranitidine, omeprazole, or eradication with omeprazole and amoxicillin or with triple therapy); and ranitidine for healing, maintenance therapy, and recurrences.

Main Cost and Outcome Measures

Rates of endoscopically proven recurrences were calculated from the meta-analysis. Recurrence costs were obtained from a consensus panel of experts. Drug costs were taken from Canadian national data sources, and therapy costs were based on provincial data (1993 Canadian dollars). Daily ranitidine cost $1.11, and daily omeprazole cost $2.72. Eradication with omeprazole and amoxicillin cost $145, and ranitidine plus triple therapy cost $124. Sensitivity analyses were done as indicated.

Main Results

Healing with immediate eradication of H. pylori had the lowest recurrence rate (20 recurrences/100 patients) and the lowest 1-year costs ($253/patient for triple therapy and $272/patient for omeprazole and amoxicillin). Initial healing with ranitidine then waiting for recurrences was associated with 108 recurrences/100 patients; 1-year costs were $329/patient for treating recurrences with ranitidine and $341/patient for omeprazole. Initial healing with ranitidine and use of eradication at recurrences were associated with 83 recurrences/100 patients; 1-year costs were $456/patient for omeprazole and amoxicillin and $445/patient for triple therapy. Healing with continuous ranitidine was associated with 20 recurrences/100 patients; 1-year costs were $386/patient. Sensitivity analyses did not change the ranking of alternatives.

Conclusion

Healing of duodenal ulcers through immediate eradication of Helicobacter pylori with either triple therapy or omeprazole and amoxicillin is more cost-effective than eradication at recurrence or maintenance therapy with ranitidine.

Source of funding: Astra Canada Incorporated.

For article reprint: Dr. B. O'Brien, Centre for Evaluation of Medicines, St. Joseph's Hospital, 50 Charlton Avenue East, H-329, Martha Wing, Hamilton, Ontario L8N 4A6, Canada. FAX 905-521-6136.


Commentary

On the basis of current evidence, few will disagree that if we eradicate H. pylori in patients with duodenal ulcers, the recurrence of ulcers should be dramatically reduced, at least over the next few years. Therefore, substantial improvements in patient care and reduced medical costs are anticipated. The study by O'Brien and colleagues makes an important attempt to show by a decision-analysis model that early H. pylori eradication is cost-effective. A limitation of the available literature is that few randomized, double-blind, controlled trials have been used to evaluate H. pylori eradication, especially in relation to duodenal ulcer recurrence, and few have been published in peer-reviewed journals. Also, the eradication treatments studied were the best available at the time, but they have generally been superseded because of unreliability. In addition, the overall eradication rates for omeprazole and amoxicillin, although taken to be 84% in the decision analysis, were only 58% in a subsequent report (1). Many of the studies in this meta-analysis were done in Europe, and although most duodenal ulcers appear to have similar pathogenic mechanisms, healing rates may not be the same in other parts of the world (2).

Not surprisingly, the authors conclude that first-year costs for treating duodenal ulcer disease remain high. The savings we anticipate should come in subsequent years, but this has yet to be shown. Another longer-term issue that has not been addressed is that of ulcer complications, hemorrhage, and perforation. The U.S. National Institutes of Health consensus statement (3) drew specific attention to doubts about whether these risks could be reduced by H. pylori eradication.

Before wide-scale changes are made to prescribing patterns for such a common and important condition as duodenal ulcer, clinical trials with full H. pylori testing that assess benefits and possible pitfalls and measure economic effects need to be done.

R. V. Heatley, MD
St. James's University HospitalLeeds, England, UK


References

1. Penston JG. Review article: Helicobacter pylori eradication--understandable caution but no excuse for inertia. Aliment Pharmacol Ther. 1994;8:369-89.

2. Dixon JS, Wood JR. The distribution of noradrenergic nerves and small, intensely fluorescent (SIF) cells in the cat urinary bladder. A light and electron microscope study. Eur J Gastroenterol Hepatol. 1992;4:147-63.

3. Anonymous. NIH Consensus Conference. Helicobacter pylori in peptic ulcer disease. NIH Consensus Development Panel on Helicobacter pylori in Peptic Ulcer Disease. JAMA. 1994;272:65-9.


Updated Commentary

The commentary highlights the fact that newer, more effective treatment regimens (involving triple therapy with a protein pump inhibitor and 2 antibiotics) are recommended.