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


Triple therapy and proton pump inhibitors had lowest costs and best outcomes for Helicobacter pylori infection

ACP J Club. 1997 Jul-Aug;127:22. doi:10.7326/ACPJC-1997-127-1-022

Source Citation

Taylor JL, Zagari M, Murphy K, Freston JW. Pharmacoeconomic comparison of treatments for the eradication of Helicobacter pylori. Arch Intern Med. 1997 Jan 13;157:87-97.



To determine the costs and outcomes of treatment of Helicobacter pylori infection with 8 antibiotic regimens and maintenance therapy using histamine2-receptor antagonists (H2RAs).


Cost-effectiveness analysis using a decision-analytic model with prescribing data from a meta-analysis of 119 studies.


Economic perspective of the U.S. health care system; clinical data from international literature.


Hypothetical cohort of adults with proven duodenal ulcer who are followed for 1 year.


8 antibiotic regimens (Table) and maintenance therapy with H2RA (daily generic cimetidine, 400 mg at bedtime).

Main cost and outcome measures

Ulcer recurrence (from meta-analysis data) and total costs adjusted for potential compliance (lower compliance rates were assigned to medications with higher dosing frequencies). Direct costs (1995 U.S. dollars) included the cost of inpatient and outpatient physician professional services (Medicare Physician Fee Schedule), testing for H. pylori infection, use of the endoscopy suite, hospitalization, and medication (mean 1995 wholesale prices). All data were adjusted for usual medication compliance.

Main results

Most antibiotic regimens had lower costs than maintenance H2RA therapy. 3 antibiotic regimens had lower costs and better outcomes (Table).


Standard triple therapy with or without a proton pump inhibitor, or clarithromycin, metronidazole, and a proton pump inhibitor had lower costs and better outcomes than H2RA maintenance therapy for Helicobacter pylori infection.

Source of funding: TAP (Takeida-Abbott Partnership) Holdings, Inc.

For article reprint: Dr. M. Zagari, Technology Assessment Group, 490 Second Street, Suite 201, San Francisco, CA 94107, USA. FAX 415-495-8969.

Table. Drug regimens, costs, eradication rate, and ulcer recurrence for H. pylori

Drug regimens Annual costs, U.S. $ Eradication rate, % Patients from from ulcer recurrrence at 1 year, %
BMT, 14 d, 4×/d* 223 80 82
CMPPI, 7 d, 2×/d* 235 84 85
BMTPPI, 7/7/7/10 d, 4×/d* 236 85 86
MAPPI, 7 d, 3×/d 261 76 80
BMA, 28/7/7 d, 4×/d 297 62 70
CAPPI, 14 d, 2×/d 339 82 84
APPI, 14 d, 2×/d 345 58 68
CPPI, 14 d, 3×/d 410 65 72
H2RA 425 72

*Consistently lower costs and better outcomes with Monte Carlo and sensitivity analyses. A = amoxicillin; B = bismuth; C = clarithromycin; H2RA = histamine2 receptor antagonist; M = metronidazole; PPI = proton pump inhibitors (omeprazole or lansoprazole); T = tetracycline.


Few medical therapies hold the promise of improving patient outcomes and lowering costs. Eradication of the bacterium H. pylori using combinations of antibiotics is 1 such breakthrough in the management of peptic ulcer disease. Although studies have shown that it is more cost-effective to eradicate the causative bacterium than to treat the symptoms with maintenance acid suppression, a key question still remains: Which eradication strategy offers the best value for money?

The study by Taylor and colleagues helps health care decision-makers address this question by comparing the costs and outcomes of 8 antibiotic and 1 acid-suppression regimens. The regimens with the lowest cost and that result in the lowest ulcer recurrence rates are bismuth triple therapy and triple therapies with proton pump inhibitors, such as omeprazole or lansoprazole.

The study is clearly presented and is a good example of the valuable synthetic techniques of meta-analysis for pooling clinical event probabilities (e.g., ulcer recurrence) and decision analysis for combining costs and events in a decision tree that maps out clinical decisions and consequences. But any model is only as good as the data on which it is built. 3 issues on data are worthy of comment. First, the authors of this model take on the challenge of trying to work antibiotic compliance into their analysis and quickly find very few reliable data. Second, the study does not include any consideration of resistance to such drugs as metronidazole. Third, a challenge for such models is that clinical trials on ulcer healing deliver efficacy data based on endoscopy that will likely "over-call" detection when compared with symptomatic presentation in real clinical practice.

These 3 gaps (and others) in evidence are unlikely to be filled by data from randomized trials in which the typical focus is efficacy and adherence to protocol (1). To make such models realistic and useful, we need to feed them data from multiple sources that reflect the actual use of the drugs in clinical practice.

Bernie J. O'Brien, PhD
McMaster UniversityHamilton, Ontario, Canada

Bernie J. O'Brien, PhD
McMaster University
Hamilton, Ontario, Canada


1. O'Brien BJ. Economic evaluation of pharmaceuticals. Frankenstein's monster or vampire of trials? Med Care. 1996;34:DS99-108.