Revisión sistemática de la terapia secuencial frente a la triple terapia clásica para la erradicación de helicobacter pylori

Resumen

Executive summary BACKGROUND: Non-bismuth quadruple sequential therapy (SEQ) has been suggested as a new first-line treatment option to replace the standard triple therapy (STT), in which eradication rates have declined to disappointing levels. AIM: To conduct a meta-analysis of studies comparing SEQ vs. STT for H. pylori eradication. METHODS: Selection of studies: randomized controlled trials (RCTs) comparing SEQ (10 days) and STT (at least 7 days) for the eradication of H. pylori. Search strategy: bibliographical searches in electronic databases and manual search of abstracts from Congresses were conducted up to May 2013. Data synthesis: intention-to-treat (ITT) eradication rate. RESULTS: 30 RCTs were included with a total of 8,878 patients (4,173 in the SEQ and 4,705 in the STT). The overall analysis showed that SEQ was significantly more effective than STT (84% vs. 74% in the ITT analysis; OR= 2.06; [95%CI= 1.59-2.66]; p<0.001). Results were highly heterogeneous (I2=78%) and 10 studies were unable to demonstrate differences between therapies. Subgroup analyses suggested that patients with clarithromycin resistance and/or taking esomeprazole-rabeprazole could benefit more from SEQ. However there were no differences when STT lasted 14 days. Although, overall, mean eradication rate with SEQ was over 80%, a tendency towards lower efficacy with this regimen was observed in the more recent studies [weighted linear regression per year -0.02 (-2% per year) in SEQ vs. -0.005 (-0.5% per year) in STT], and in studies performed outside Italy (OR 1.48 vs. 4.09). CONCLUSION: The meta-analysis demonstrated that SEQ is more effective than STT lasting less than 14 days. Nevertheless, the apparent advantage of sequential treatment seems to be decreasing overtime; therefore further and continuous assessment is needed before a generalized change in all settings is recommended for first line H. pylori treatment.