Vakil N, Fennerty M B
University of Wisconsin Medical School, Milwaukee, USA.
Am J Gastroenterol. 1996 Feb;91(2):239-45.
Eradication of Helicobacter pylori with antimicrobials was recommended by a recent NIH consensus panel for all infected patients with peptic ulcer disease. The precise regimen that should be used for eradication of the infection remains uncertain because of the variety of regimens described, variable results with the regimens, and difficulties in predicting drug compliance outside clinical trials.
A decision analysis tree was developed with three regimens that are widely used regimens for the eradication of H. pylori: 1) 2-wk triple drug therapy (metronidazole, bismuth, tetracycline with H2 receptor antagonist), 2) 2-wk omeprazole and amoxicillin, and 3) 2-wk omeprazole and clarithromycin. Traditional H2 receptor antagonist therapy was used for comparison. A 2-yr time period was chosen for study to allow sufficient time for relapse and to evaluate its effect on the treatment strategy. Probabilities for eradication, compliance, and metronidazole resistance were determined from published data, and assumptions were tested by sensitivity analysis.
Standard 2-wk triple drug therapy was the least expensive strategy ($720), and conventional H2 receptor antagonist therapy was the most expensive ($1791). Costs with 2-wk therapy with omeprazole and clarithromycin ($768) were lower than with omeprazole and amoxicillin ($1028).
Treatment to eradicate H. pylori in infected patients with duodenal ulcer is a less expensive strategy than traditional therapy with H2 receptor antagonists. Triple drug therapy is the optimal regimen in areas where metronidazole resistance rates are < 36% and compliance is > 53%. Omeprazole and amoxicillin is not cost-effective unless eradication rates are greater than 74%. Dual drug therapy with omeprazole and clarithromycin is effective in regions where metronidazole resistance is high or where it is anticipated that there would be poor compliance with the more complicated triple drug therapy regimen.
美国国立卫生研究院（NIH）最近的一个共识小组建议，所有感染幽门螺杆菌的消化性溃疡病患者均应使用抗菌药物根除幽门螺杆菌。由于所描述的治疗方案多种多样、各方案的治疗效果不一以及在临床试验之外难以预测药物依从性，因此对于根除该感染究竟应采用何种确切方案仍不确定。
构建了一个决策分析树，其中包含三种广泛用于根除幽门螺杆菌的治疗方案：1）为期2周的三联药物疗法（甲硝唑、铋剂、四环素加H2受体拮抗剂）；2）为期2周的奥美拉唑和阿莫西林疗法；3）为期2周的奥美拉唑和克拉霉素疗法。采用传统的H2受体拮抗剂疗法作为对照。选择2年的时间段进行研究，以便有足够的时间观察复发情况并评估其对治疗策略的影响。根除率、依从性和甲硝唑耐药性的概率根据已发表的数据确定，并通过敏感性分析对假设进行检验。
标准的为期2周的三联药物疗法是成本最低的策略（720美元），而传统的H2受体拮抗剂疗法成本最高（1791美元）。为期2周的奥美拉唑和克拉霉素疗法的成本（768美元）低于奥美拉唑和阿莫西林疗法（1028美元）。
对于感染幽门螺杆菌的十二指肠溃疡患者，根除幽门螺杆菌的治疗策略比传统的H2受体拮抗剂疗法成本更低。在甲硝唑耐药率低于36%且依从性高于53%的地区，三联药物疗法是最佳方案。除非根除率大于74%，否则奥美拉唑和阿莫西林疗法不具有成本效益。在甲硝唑耐药性较高或预计对更复杂的三联药物治疗方案依从性较差的地区，奥美拉唑和克拉霉素的双联疗法有效。
