From Mr C. D. R. Dunn, MRPharmS and Dr R. Harvey, FRCP
SIR,-We were interested to read the paper by Wathen et al (PJ, June 24, p959) that confirms previous anecdotal reports1 of the potential savings to be achieved by switching patients from therapeutic to maintenance doses of proton pump inhibitors (PPIs). While this may be appropriate for a minority of patients,2 the underlying cause of the symptoms should be considered, because of the potential for curing the underlying problem and thus avoiding the need for expensive, long-term maintenance acid suppression.
A significant proportion of patients taking long-term PPIs at whatever dose will be doing so because their dyspeptic symptoms are caused by peptic ulcer disease related to chronic infection with Helicobacter pylori. More than 90 per cent of patients with duodenal ulcer and about 70 per cent of patients with gastric ulcer have H pylori infection, and most would be cured of their ulcers by a course of H pylori eradication therapy3,4 at an approximate cost equivalent to one month's treatment with a PPI.5 Likewise, although more controversial, there is some evidence that patients taking non-steroidal anti-inflammatory drugs (NSAIDs) are more at risk of peptic ulceration if they are infected with H pylori and that prior eradication of the bacterium will lower this risk.6,7 Eradication of H pylori might, therefore, reduce the need for either therapeutic or maintenance doses of PPIs in patients taking NSAIDs, and result in a long-term reduction in the costs of these medicines in such patients. It has been known for some years that, even allowing for the costs of testing for H pylori infection and for the costs of treatment failure in a small proportion of patients, H pylori eradication therapy is a cost-effective way to manage patients with peptic ulcers.8,9
The benefits of eradication therapy for patients with non-ulcer dyspepsia are less certain,10 and eradication may not be so cost-effective in populations with a lower prevalence of H pylori infection. But in these patients screening and appropriate eradication therapy may have the added benefit of reducing the risk of subsequent development of gastric cancer.
Christopher D. R. Dunn
Senior Research Fellow, University of the West of England, Bristol
Richard Harvey
Consultant Gastroenterologist, Frenchay Hospital, North Bristol NHS Trust
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