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									                                                                                                                         Álvaro Nagib Atallah*

                            Evidence for the treatment of chronic peptic ulcer

         or many years surgery was considered an important               remain of what to elo in practice? Two recent trials have

P       approach for the treatment of chronic peptic ulcer.
        Thousands of patients were submitted to surgery in
the absence of appropriate controlled trials. If such trials
                                                                         been publisheel that may help to aelress this questiono
                                                                                Boer e col.', in "Quadruple therapy erradicated H.
                                                                         pylori-associated      peptic ulcer disease better than dual
had been undertaken, the history ofthe disease could have                therapy", compared quadruple therapy (n = 40) with dual
been different. Once the link between Helicobacter pylori                therapy (n = 36). Quaelruple therapy inclueled orneprazole
infection and chronic peptic ulcer had been established,                 - 20 mg twice daily on elays I to 10; colloielal bismuth
new treatment guidelines based on scientific evidence were               subcitrate, 120 mg, 4 tirnes/d, on elays 4 to 10; tetracycline
required.                                                                hydrocloride,      500 rng, 4 times/d, on elay 4 to 10; and
       If the interested    c1inician were to consult the                metronidazole 500 mg, 3 times/eI, on days 4 to 10. Dual
Cochrane Library, he would find no systematic review                     therapy includeel orneprazole, 20 mg twice daily, on days
prepared by the Cochrane Collaboration Group, but two                     1 to 14 anel arnoxicillin, 1000 rnh twice daily, on days I to
reviews prepared by outside the collaboration.        One of              14. The studied patients where who had chronic peptic
these, focuses on the effectiveness       and the economic               ulcer disease anel eneloscopically       proved Helicobacter
aspects of treatrnent ', and other on the efficacy of                    Pylori infections. The effects were biopsy confirmed.
antibiotictherapy in erradicating Helicobacter pylori. 2 Both                    Quadruple therapy leel to a higher cure rate than elicl
have been assessed by the Cochrane Collaboration.                        dual therapy 93% vs 56%, P < 0,00 I. The rate of adverse
Basically the studies are supposed to compare placebo with               effects was higher in the group that receivecl quaclruple
omeprazole plus amoxicillin, or these two (dual therapy)                 therapy than elual therapy group.
with triple therapy       (colloidal   bismuth   subcitrate,
                                                                                 Thijs e col.vcompared triple therapy, colloidal bisrnuth
metronidazole      and tetracycline)  ar quadruple therapy
                                                                          subcitrate, 120 mg, 4 ti mes/eI, metronidazole 250 rng, 4
(omeprazole,     colloidal bismuth subcitrate, tetracycline
                                                                         tirnes/d, and tetracycline 250 mg, 4 times/d, with dual
hyelrochloriele and rnetronidazole).
                                                                         therapy, omeprazole 40 mg twice elaily anel amoxicillin 1000
       As can be seen, we have many agents to be compareel
                                                                          mg twice daily. Both regimens were taken for 14 days. Triple
two by two, three by three, four by four, or even to use
                                                                         therapy led to a higher rate of cure than dual therapy (95%
thern alI. Obviously, when the number of agents increases,
                                                                          vs 70%, P < 0,00 I). Again siele effects were more frequently
the chances of aelverse effects and cost increases. Hence
                                                                          associateel with triple than with elual therapy.
there are many questions that neeel to be answereel by
                                                                                 Although more larger trials are needed, the reader
appropriate research. If we look at the Cochrane Library
                                                                          can already make a therapeutic decision, keeping in minei
elatabase, we finei 157 references on this subject. While it
                                                                          that the fewer elrugs useel increases cornpliance anel reduces
is gooel news that there is so much information, the question
                                                                          side effects.
                                                                                 Besieles the inforrnation in the Cochrane Library the
*   MO, PhO, MCE
                                                                          reader can also refer to the cornrnentary on the papel' by
    Chairman, Oepartment of Intemal Medicine, Escola                      Schoenfeld anel Butler 4, anel will have more evielence to
    Paulista de Medicina, Editor, São Paulo Medical Joumal.               guide his pratice.

ATALLAH. A.N. - Evidence   for the treatment   of chronic peptic ulcer                 São Paulo Medicat   Journat/RPM    115(1): 1327-1328,   1997

REFERENCES                                                                          3.    Moore       RA. Hclicobactcr        pvloti .uul pcptic ulccr: a syslL'lllal il'
                                                                                          revicw       of etfecrivencss          and a     ovcrvie       w of thc cconomic
                                                                                          benefits      of implementiug             wh.u is KII()\\'n        to bc ctlcctive.
I.   Boer WA. Driessen               WM,   Jansz AR, Tytgat      GN. Quadruple            Oxford:       Pain RcliefResearch              Unit     VII:   37. 1()()5.
     therapy     compared  with dual therapy        for eradication     of          -I.   Schoenfeld         PS, Butlcr      .IA.            1:\ iilcucc      llased
     l lcluobcutcr pvlori i n ulcer patients: results of a randornized                    Medicine        1996: 1(4): 109- 1O.
     prospective single-centre    srudy. Eur J Gastroenterol Hepatol                5.    Thijs.lC.        van Zwci        AA.      l\loolcnaar          W. WolfliagcII            \1.1.
     1995:7: 11X9-9-1.                                                                    Huinink       JB. Triple   therapy        vs amo x icil lin plus omcpr.i/o!«
     Chiba N. Rao I3V. Radernaker       JW, I-1Ullt RI-I. Meta-analysis                   for   the     treutrnent    of    Hcl icob a ct c r pvl o ri i n le ct i o n:                 ;1

     of   the   c líi cuc   y   of    antibiotic    therapy      in   eradicating         multicenrer,       prospective.         randorni      zcd. conuo        llcd 'llItJ)        uf
     t lelicobactcr    pvlori. AIl1.J Gastroenterol           1992:87 (12): 1216-         cff'icacy anel side elTects. Am J Gaxtroc utcrol                        1()l)!>:   l)   1:'!:i-
      1727.                                                                               7.

São Paulo Medical Journal/RPM              115(1): 1327-1328, 1997                                    ATALLAH, A.N. - Evidence for lhe Ireatment of chroruc peptic ulcer

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