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Á l v a r o N a g i b A t a l i a h *

E v id e n c e fo r th e tre a tm e n t o f c h ro n ic p e p tic u lc e r

P

o r m a n ya p p r o a c h y e a r s s u r g e r yf o r th e tr e a tm e n tw a s c o n s id e r e do f c h r o n ic a n im p o r ta n tp e p tic u lc e r o T h o u s a n d s o f p a tie n ts w e r e s u b m itte d to s u r g e r y in

th e a b s e n c e o f a p p r o p r ia te c o n tr o lle d tr ia ls . I f s u c h tr ia ls

h a d b e e n u n d e r ta k e n , th e h is to r y o f th e d is e a s e c o u ld h a v e

b e e n d if f e r e n t. O n c e th e lin k b e tw e e n

Helieobaeter

pylori

in f e c tio n a n d c h r o n ic p e p tic u lc e r h a d b e e n e s ta b lis h e d ,

n e w tr e a tm e n t g u id e lin e s b a s e d o n s c ie n tif ic e v id e n c e w e r e

r e q u ir e d .

I f th e in te r e s te d c lin ic ia n w e r e to c o n s u lt th e

C o c h r a n e L ib r a r y , h e w o u ld f in d n o s y s te m a tic r e v ie w

p r e p a r e d b y th e " C o c h r a n e C o lla b o r a tio n G r o u p , b u t tw o

r e v ie w s p r e p a r e d b y o u ts id e th e c o lla b o r a tio n . O n e o f

th e s e , f o c u s e s o n th e e f f e c tiv e n e s s a n d th e e c o n o m ic

a s p e c ts o f tr e a tm e n t3

, a n d o th e r o n th e e f f ic a c y o f

a n tib io tic th e r a p y in e r r a d ic a tin g

Helieobaeter pylori.

2B o th

h a v e b e e n a s s e s s e d b y th e C o c h r a n e C o lla b o r a tio n .

B a s ic a lly th e s tu d ie s a r e s u p p o s e d to c o m p a r e p la c e b o w ith

o m e p r a z o le p lu s a m o x ic illin , o r th e s e tw o ( d u a l th e r a p y )

w ith tr ip le th e r a p y ( c o llo id a l b is m u th s u b c itr a te ,

m e tr o n id a z o le a n d te tr a c y c lin e ) o r q u a d r u p le th e r a p y

( o m e p r a z o le , c o llo id a l b is m u th s u b c itr a te , te tr a c y c lin e

h y d r o c h lo r id e a n d m e tr o n id a z o le ) .

A s c a n b e s e e n , w e h a v e tn a n y a g e n ts to b e c o m p a r e d

tw o b y tw o , th r e e b y th r e e , f o u r b y f o u r , o r e v e n to u s e

th e m a lI . O b v io u s ly , w h e n th e n u m b e r o f a g e n ts in c r e a s e s ,

th e c h a n c e s o f a d v e r s e e f f e c ts a n d c o s t in c r e a s e s . H e n c e

th e r e a r e m a n y q u e s tio n s th a t n e e d to b e a n s w e r e d b y

a p p r o p r ia te r e s e a r c h . I f w e lo o k a t th e C o c h r a n e L ib r a r y

d a ta b a s e , w e f in d 1 5 7 r e f e r e n c e s o n th is s u b je c t. W h ile it

is g o o d n e w s th a t th e r e is s o m u c h in f o r m a tio n , th e q u e s tio n

* M O , P h O , M C E

C h a i r ma n , O e p a r t m e n t o f I n t e r n a i Me d i c i n e , E s c o l a P a u l i s t a d e M e d i c i n a , E d i t o r , S ã o P a u l o M e d i c a i J o u r n a l .

r e m a in o f w h a t to d o in p r a c tic e ? T w o r e c e n t tr ia ls h a v e

b e e n p u b lis h e d th a t m a y h e lp to a d r e s s th is q u e s tio n o

B o e r e c o l.', in " Q u a d r u p le th e r a p y e r r a d ic a te d H .

p y lo r i- a s s o c ia te d p e p tic u lc e r d is e a s e b e tte r th a n d u a l

th e r a p y " , c o m p a r e d q u a d r u p le th e r a p y ( n =4 0 ) w ith d u a l th e r a p y ( n =3 6 ) . Q u a d r u p le th e r a p y in c lu d e d o m e p r a z o le

- 2 0 m g tw ic e d a ily o n d a y s 1 to 1O ~ c o llo id a l b is tn u th

s u b c itr a te , 1 2 0 m g , 4 tim e s /d , o n d a y s 4 to 1O ~te tr a c y c lin e

h y d r o c lo r id e , 5 0 0 m g , 4 tim e s /d , o n d a y 4 to 1O ~ a n d

m e tr o n id a z o le 5 0 0 m g , 3 tim e s /d , o n d a y s 4 to 1 0 .D u a l

th e r a p y in c lu d e d o m e p r a z o le , 2 0 m g tw ic e d a ily , o n d a y s

1to 1 4a n d a m o x ic illin , 1 0 0 0 m h tw ic e d a ily , o n d a y s l to

1 4 . T h e s tu d ie d p a tie n ts w h e r e w h o h a d c h r o n ic p e p tic

u lc e r d is e a s e a n d e n d o s c o p ic a lly p r o v e d

Helieobaeter

Pylori

in f e c tio n s . T h e e f f e c ts w e r e b io p s y c o n f in n e e l.

Q u a d r u p le th e r a p y le d to a h ig h e r c u r e r a te th a n d id

d u a l th e r a p y 9 3 % v s 5 6 % , P < 0 ,0 0 1 . T h e r a te o f a d v e r s e e f f e c ts w a s h ig h e r in th e g r o u p th a t r e c e iv e d q u a d r u p le

th e r a p y th a n d u a l th e r a p y g r o u p .

T h ijs e c o l.5

c o m p a r e d tr ip le th e r a p y , c o lI o id a l b is ln u th

s u b c itr a te , 1 2 0 m g , ~ tim e s /d , ln e tr o n id a z o le 2 5 0 ln g , 4

tim e s /d , a n d te tr a c y c lin e 2 5 0 m g , 4 tiln e s /d , w ith d u a l

th e r a p y , o m e p r a z o le 4 0 m g tw ic e d a ily a n d a tn o x ic ilI in 1 0 0 0 .

m g tw ic e d a ily . B o th r e g im e n s w e r e ta k e n f o r 1 4 d a y s . T r ip le

th e r a p y le d to a h ig h e r r a te o f c u r e th a n d u a l th e r a p y ( 9 5 %

v s7 0 % , P<0 ,0 0 1 ) .A g a in s id e e f f e c ts w e r e m o r e f r e q u e n tly a s s o c ia te d w ith tr ip le th a n w ith d u a l th e r a p y .

A lth o u g h m o r e la r g e r tr ia ls a r e n e e d e d , th e r e a d e r

c a n a lr e a d y m a k e a th e r a p e u tic d e c is io n , k e e p in g in m in e i

th a t th e f e w e r d r u g s u s e d in c r e a s e s c o m p lia n c e a n d r e d u c e s

s id e e f f e c ts .

B e s id e s th e in f o r m a tio n in th e C o c h r a n e L ib r a r y th e

r e a d e r c a n a ls o r e f e r to th e c o m m e n ta r y o n th e p a p e r b y

S c h o e n f e ld a n d B u tle r 4 , a n d w ill h a v e m o r e e v id e n c e to

g u id e h is p r a tic e .

(2)

1328

REFERENCES

I. B o e r W A , D rie s s e n W M , J a n s z A R , T y tg a t G N . Q u a d ru p le

th e ra p y c 0 l1 1 p a re c l w ith d u a l th e ra p y fo r e ra d ic a tio n o f

Helico!Jacter

py/ori

in u lc e r p a tie n ts : re s u lts o f a ra n d o l1 1 iz e e l p ro s p e c tiv e s in g le -c e n tre s tu e ly . E u r J G a s tro e n te ro l H e p a to l

1995;7: 1189-94.

2 . C h ib a N , R a o B V , R a e le rn a k e r J W , H u n t R H . M e ta -a n a ly s is

o f th e .e ffic a c y o f a n tib io tic th e ra p y in e ra e lic a tin g

/-/e/icohacterpy/ori.

A n l J G a s tro e n te ro l 1992:87 (12):

1216-1727.

S ã o P a u lo M e d ic a i J o u rn a l/R P M 1 1 5 (1 ): 1 3 2 7 -1 3 2 8 , 1 9 9 7

3. M o o re

RA./-/elico!Jacter

jJy/ori

a n e l p e p tic 1 Ilc c r: a s y s tc llla tic

re v ie w o f e ffe c tiv e n e s s a n e l a o v e rv ie \v

o r

th e e c o llo lllic

b e n e fits o f irn p le l1 1 e n tin g w h a t is k llo \v n to b e e ffe c ti v e .

O x fo re l: P a in R e lie f R e s e a rc h U n it V II~ 3 7 , 1 9 9 5 .

4 . S c h o e n fe le l P S , B u tle r .T A . C o n ll1 1 e n ta ry . E v ic lc llc e B a s e d M e e lic in e 1996; 1(4): 109-10.

5 . T h ijs J C , v a n Z w e t A A , M o o le n a a r W , W o lfh a g c ll

rvu.

H u in in k J E . T rip le th e ra p y v s a rllo x ic illin p llls o llle p ra z o le

fo r th e tre a trn e n t o f

/-/e!ico!Jacter

jJy/ori

in fe c tio ll:. a

n lu ltic e n te r, p ro s p e c tiv e , ra n e lo n liz e d , c o n tro lle d s tL ic ly o f

e ffic a c y a n e l s id e e ffe c ts . A n l JG a s tro c n te ro l 1996: 91 :93-7 .

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