Review
Am J Gastroenterol advance online publication 20 October 2009; doi: 10.1038/ajg.2009.555
Sequential Therapy or Triple Therapy for Helicobacter pylori Infection: Systematic Review and Meta-Analysis of Randomized Controlled Trials in Adults and Children
Luigi Gatta MD1,2, Nimish Vakil MD, FACG3,4, Gioacchino Leandro MD2, Francesco Di Mario MD2 and Dino Vaira MD5
- 1Versilia Hospital, Lido di Camaiore, Italy
- 2Department of Clinical Science, Section of Gastroenterology, University of Parma, Parma, Italy
- 3Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- 4Department of Medicine, Marquette University College of Health Sciences, Milwaukee, Wisconsin, USA
- 5Department of Internal Medicine and Gastroenterology, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
Correspondence: Luigi Gatta, MD, Department of Clinical Science, Section of Gastroenterology, University of Parma, via Gramsci 14, Parma 43100, Italy. E-mail: gattaluigi@yahoo.it
Received 13 November 2008; Accepted 25 March 2009; Published online 20 October 2009.
Abstract
OBJECTIVES:
Eradication rates with triple therapy (TT) for Helicobacter pylori infection have declined to unacceptable levels. Sequential therapy (ST) is a novel treatment that has shown promise in several controlled trials. Our aim was to assess the efficacy of ST in adults and children compared with that of TT by performing a systematic review and meta-analysis.
METHODS:
We performed an electronic search of the following: Cochrane Trial Register (until Issue 4, 2008), MEDLINE (1966 to 21 October 2008), EMBASE (1980 to 21 October 2008), and abstracts from the major US, European, and Asian gastroenterology conferences. Randomized controlled trials (RCTs) and controlled clinical trials with a parallel group design comparing the ST with a TT lasting at least 7 days were used.
RESULTS:
Ten RCTs enrolled 3,006 adult patients and the odds ratio (OR) for eradication of H. pylori with ST compared with TT was 2.99 (95% confidence interval (CI): 2.47–3.62), giving a number needed to treat (NNT) of 6 (95% CI: 5–7) favoring ST. There was no publication bias. The OR for eradication with ST compared with 10-day TT was 2.92 (95% CI: 1.95–4.38), yielding an NNT of 8 (95% CI: 6–12), favoring ST. In patients with clarithromycin resistance, the OR for eradication with ST was 10.21 (95% CI: 3.01–34.58) compared with TT, but the numbers studied are small. Three RCTs enrolled 260 children and adolescents, and the OR for eradication was 1.98 (95% CI: 0.96–4.07). There was no difference in the rate of side effects between the ST and the TT (OR, 1.01; 95% CI: 0.78–1.30).
CONCLUSIONS:
ST appears to be better than TT in the eradication of H. pylori. This is a promising therapy, but further trials are needed in other European countries and North America before it can be recommended as a first-line treatment.
