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Relapse of duodenal ulcer: does it matter which drug is used in initial treatment?

1986; BMJ; Volume: 293; Issue: 6555 Linguagem: Inglês

10.1136/bmj.293.6555.1117

0959-8138

J. Philip Miller, E. Brian Faragher,

Gastroesophageal reflux and treatments

diRelapse of duodenal ulcer: does it matter which drug is used in initial treatment?Duodenal ulcers recur within a year in 80-90% of patients treated initially with H2 antagonists,'-' and evidence now exists that relapse rates may be lower after treatment with other ulcer healing drugs.Moshal postulated in 1978 that relapse rates might be lower after treatment with tripotassium di-citrato bismuthate (Moshal MG, Sixth World Congress of Gastroenterology, Madrid, 1978), and in a double blind prospective study we showed that this was indeed so.9 McLean and others'" have concluded that this may also be true for other ulcer healing drugs, including antacids," anticholinergics,'2 antacid and anticholinergic combinations,'3 carbenoxolone,'4 1 ' sucralfate,'6 and trithiozine. 17 18vidence for a reduction in relapse rate relative to cimetidine is not, however, strong for most of these agents individually.The studies have often been small, and the differences have also been small, either failing to reach significance or doing so only transiently.For example, Hansky and others claimed no significance for the difference in relapse rates that they observed in a small study of antacids against cimetidine," and larger studies have found no difference.'920The strength of the argument of McLean and others'0 is, however, that when an appreciable difference in relapse rates is observed it is consistently in favour of the comparative agent and to the detriment of cimetidine.Only in the case of tri-potassium di-citrato bismuthate is there sufficient evidence for a single drug that the effect is real.Although our initial study was not immediately con- firmed,2' four subsequent trials22-29 have shown lower relapse rates after tri-potassium di-citrato bismuthate than after an H2 antagonist.The more recent ofthese studies23125 strengthen the case made by McLean and others and extend it to include ranitidine, which is followed by a similar relapse rate to cimetidine.The consistency of the results leaves little doubt that the phenomenon is genuine, and in a further trial recurrence rates were similar in patients maintained on cimetidine and those given only a short course of tripotassium di-citrato bismuthate to induce healing.26Combining results from the six studies showed that 85% of patients treated with H2 antagonists relapse within a year compared with 59% of those treated with tri-potassium di- citrato bismuthate.9 2-Combining data from clinical trials is unreliable, but this is the best available quantitative estimate of the difference between the treatments.Because duodenal ulceration is so common even a difference of about 25% has